The Health Care Manager Volume 32, Number 4, pp. 370–379 Copyright # 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Use of Innovative Advance Directives Programs in Nursing Homes Jullet A. Davis, PhD End-of-life service providers continue to seek improved instruments for individuals to convey their last wishes. Two such instruments are Five Wishes and Physician Order for Life-Sustaining Treatment. This project explores the relationship of nursing home profit status and innovativeness to the use of these advance directive programs (ADPs). The specific aims of this study were to determine what other types of innovations are associated with the use of these ADPs and the differences in use by nursing home characteristics. Data for this project come from the 2004 National Nursing Home Survey (n = 949). The data were analyzed using 3 logistic regression models. The results revealed that quality-of-life activities, having an in-house hospice, being a notfor-profit chain-affiliated nursing home, or a for-profit freestanding nursing home were all associated with ADP. These results suggest that ADP use may be influenced by nursing home characteristics other than clinical services. Key words: end-of-life care, hospice, innovations, nursing homes, profit status
S RESEARCH AND practitioners alike continue to struggle with developing and defining the factors associated with a ‘‘good death,’’ most would agree that the communicating and honoring of a person’s final wishes are an integral component toward achieving this goal.1,2 The passage of the Patient Self-determination Act of 1990 made it mandatory that health care providers, including nursing homes, receiving Medicaid and Medicare reimbursement inform residents at the time of admission of their rights to express their final wishes using an advance directive.3 Currently, the popular instruments used to convey final wishes are as living wills, do-not-resuscitate, health care proxies, durable power of attorney, and do-not-hospitalize orders.
A
Author Affiliation: Management Department; and Center for Mental Health and Aging, The University of Alabama, Tuscaloosa, Alabama. The author has no conflicts of interest. Correspondence: Jullet A. Davis, PhD, Management Department, The University of Alabama, Box 870225, Tuscaloosa, AL 35487 ([email protected]). DOI: 10.1097/HCM.0b013e3182a9d6d2
Yet, these instruments face numerous limitations in that they may not fully reflect the nuances of a person’s wishes (for instance, who should be present with the patient), or providers (such as paramedics) may fail to enforce these directives.4 The limitations of the more traditional instruments suggest there is room for new methods by which patients can communicate their final wishes and have those wishes honored. DESCRIPTION OF THE PROBLEM Five Wishes and the Physician Order for LifeSustaining Treatment (POLST) paradigm program may each represent an innovation in advance directive programs (ADPs) in that they either attempt to address final wishes comprehensively or they are directed to providers, which may increase the likelihood of compliance.5 The POLST paradigm program documents final wishes in the form of medical orders.6 The POLST guides the treatment decisions of all medical personnel including emergency medical technicians, physicians, and nurses. Physician Order for Life-Sustaining Treatment is in use in 16 states, with another 27 states developing programs (Figure 1). Five Wishes, on
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Figure 1. States with POLST Paradigm Programs. Source: Center for Ethics in Health Care, Oregon Health & Science University, 2013.
the other hand, addresses the individual’s wishes in 5 distinct areas: (1) the appointment of a surrogate decision maker, (2) the kind of medical treatment desired or not, (3) the level of comfort, (4) how people should treat the patient, and (5) what information should be shared with loved ones.7 ‘‘Five Wishes meets the legal requirements in 42 states (Figure 2) . . .’’ but may be used as a guide for writing an advance directive in all 50 states (Aging With Dignity,7 para. 1). STUDY PURPOSE Resnick and Foster,5 Resnick,8 and Miller and Han9 presented data from the National Nursing Home Survey (NNHS) on the trends in the presence of 1 or more of the ADP instruments noted above. Although these data help us to understand the scope of the
utilization of these instruments, it remains unclear what factors are associated with the use of the ADPs of interest. The specific aims of this study were to determine: (1) what other types of end-of-life innovations are associated with the use of these unique ADPs and (2) differences in ADP use by nursing home organizational characteristics. Nursing home innovation Rowe and Boise10(p6) defined organizational innovation as ‘‘the successful utilization of processes, programs, or products which are new to an organization and which are introduced as a result of decisions made within that organization.’’ In a later piece, they noted that an organization is innovative only if the processes, programs, or products are implemented in advance of an external market demand.11 Thus, rarity (as well as timing) is an integral feature
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Figure 2. States with Five Wishes programs. Source: Aging With Dignity,7 2012.
of innovation. Given that the oldest of the 2 ADPs of interest, POLST, was established in the mid-1990s, and that as of 2003, only approximately 13% of nursing home residents have 1 or more of these ADPs, it may be reasonable to assert that these ADPs may represent a new innovation in end-of-life care.5,12 Some researchers found that nursing homes that are innovative in one service area may also be innovative in others.13,14 The innovativeness of a nursing home may be associated with benefits in resident outcomes. Thus: Hypothesis 1: Nursing homes that offer other innovations will be more likely to offer 1 or more ADPs than will noninnovative nursing homes. Ownership status and chain affiliation There are numerous theoretical and empirical studies in the management and health care literature addressing the motivating principles guiding not-for-profit (NP) behaviors.15,16 According to the seminal theories of Bays,17 Hansmann,18 and Weisbrod,19 NP firms differ from for-profit (FP) firms along 3 key dimensions. First, NP firms offer services that the market may not offer given the cost of the services or the nature of the service. Second, NP firms may focus on aspects or qualities of a service that FP firms may fail to adequately address. Finally, the motivations of NP firms may differ from that of FP firms, thus ensuring that criteria other than profits are a vital component
of service development. This key difference between NP and FP firms is evident within the nursing home industry given variations in service provision by facility ownership. For example, Dobalian20 reported that residents living in NP nursing homes were more likely than residents living in FP nursing homes to have a living will. However, a key moderator of ownership may be membership in a multifacility chain. Researchers have found that the benefits of membership in a multifacility chain may allow nursing homes better access to additional resources, knowledge, skills, shared labor costs, and various care technologies.21-24 Thus, chainaffiliated nursing homes may be better positioned to take full advantage of care innovations.21 However, much of the research exploring chain membership and the use of ADPs found either no relationship or greater use by independent facilities.9,20,25 Nonetheless, the study of Levy et al26 suggests that the interaction of ownership and chain membership may yield more fruitful findings. Their study found that residents residing in NP independent nursing homes were more likely to have a do-not-resuscitate or a do-not-hospitalize order than residents in FP chain or FP independent nursing homes. Based on the prior findings, it is likely that: Hypothesis 2: Nursing homes operated as independent NP facilities are more likely to use ADPs than any other category of facilities.
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Advance Directives Programs in Nursing Homes METHODS Sample Data for this project come from the 2004 NNHS. This data set is used as it remains the only nationally available sample documenting the presence of the POLST Program and Five Wishes in nursing home setting. The NNHS is a publicly available series of nationally representative surveys of nursing homes across the nation and includes information on the services, staff, and residents of these homes. The sampling process consisted of a stratified 2-stage probability design. In the first stage, facilities were stratified by bed size and metropolitan area. Within these strata, facilities were then grouped by certification status, hospital-based or freestanding, ownership, geographic region, state, county, and zip code. Next, individual facilities were chosen using systematic sampling with probability proportional to the number of facility beds. Using this method, 1500 nursing homes were selected and contacted; a total of 1174 nursing homes chose to participate in the survey. The sampling process was designed to allow for generalization back to the entire population of nursing homes (16 000). After removing observations with missing data, the final sample for this study consisted of 949 nursing homes (weighted sample = 13 261). The project was approved by the institutional review board of the University of Alabama (IRB# EX-12-CM-049).
Variables Dependent variables The dependent variable is a sum of the 2 ADPs: POLST Program and Five Wishes. The NNHS asks respondents: ‘‘Does this facility participate in the following End-of-Life Programs?’’ The response options were dichotomous (yes/no). Three dependent variables were created. The first measures the use of either POLST or Five Wishes. The next 2 dependent variables measure POLST and Five Wishes individually.
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Independent variables Several independent variables were included to measure various organizational factors that categorize nursing home innovations, ownership, and chain affiliation. Nursing Home Innovations. Innovation is operationalized using several measures designed to capture staffing, quality of life, and clinical service innovations. The first variable comes from a survey question that asks if the medical director has advanced education in palliative/end-of-life care. Castle et al27 argue that top managers, which may include the medical director, are instrumental in guiding the behaviors of their respective nursing homes. This was a dichotomous measure, with yes coded as 1. The next variable captures activities associated with resident quality-of-life innovations. The 3 variables chosen from the NNHS have each been shown by other research to improve resident quality of life.28,29 The NNHS asked respondents if they offered gardening, pets or pet therapy, or intergenerational activities. The number of ‘‘yes’’ responses was summed. Clinical service innovations represent the nursing home’s venture into subacute services and hospice care, which requires a great deal of expertise.30 The service choices are dialysis-hemo, dialysis-peritoneal, infusion therapy, peripherally inserted central lines, ventilator/pulmonary therapy, bladder scanner, blood transfusions, and parenteral nutrition. The responses were summed to capture the total number of care innovations offered by each nursing home. The in-house hospice question is composed of 3 questions from the survey. The questions ask respondents if there are clusters of beds for hospice, special program/staff for hospice, and special program/ staff for palliative/end of life. The 3 questions were summed and then dichotomized to capture the percentage of nursing homes that offer on-site hospice care. Ownership and chain affiliation The NNHS categorizes nursing home ownership as either FP or all others. The all-other category includes private and government NP nursing home. Chain membership is a dichotomous
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variable with the choice of either chain member or freestanding (independent). Using these 2 variables, ownership and chain affiliation, 4 dichotomous variables were created, with each representing a unique combination, NP/ independent, NP/affiliated, FP/independent, and FP/affiliated.
Potential confounders As the decision to offer these types of ADPs may be affected by factors other than innovation and ownership, additional potential confounders were included in the model. The analysis included controls for the presence of registered nurses, Medicaid, Medicare, the number of beds, and occupancy rate. For each of these variables, the NNHS recoded the actual percent into groups; therefore, the actual percentage for each is not given in the data set. The number of registered nurse hours adjusted by resident days was collapsed across 6 categories: 1 = 0 to 0.125, 2 = 0.125 to 0.24, 3 = 0.25 to 0.49, 4 = 0.5 to .99, 5 = 1 to 1.99, and 6 = 2 or more. The percentage of residents with Medicaid as the primary payment source was aggregated into 5 categories: 1 = 0% to 19%, 2 = 20% to 39%, 3 = 40% to 59%, 4 = 60% to 79%, and 5 = 80% or more. The Medicare as primary payment source was aggregated differently, with 1 = 0% to 9%, 2 = 10%% to 19%, and 3 = 20% or more. The number of beds in the nursing home was grouped as follows: 1 = 3 to 49, 2 = 50 to 99, 3 = 100 to 199, and 4 = 200+ beds. Finally, occupancy rate was grouped into categories: 1 = less than 70%, 2 = 70% to 79%, 3 = 80% to 89%, 4 = 90% to 94%, and 5 = 95% or more.
Data analysis The SVYSET option in Stata version 12 was used, which accounts for the multistage probability design of the NNHS. The data were analyzed using logistic regression. Three separate models are presented. In the first, the use of any ADP was examined. The second and third models analyzed Five Wishes and POLST program, respectively.
FINDINGS The sample characteristics reveal that approximately 16% of nursing homes participated in the POLST program or Five Wishes (Table 1). When it comes to staffing, 12% of nursing homes reported having a medical director with some form of palliative or end-of-life training. Nursing homes reported having gardening, pets or pet therapy, and intergenerational activities (mean, 2.51 [SD, 0.76]). However, few nursing homes offer more than 2 (mean, 1.51 [SD, 1.54]) of the clinical services listed in the NNHS, with parenteral nutrition (mean, 48%) followed by infusion therapy (mean, 43%) the most commonly offered. More than 31% reported having either special programs/staff for hospice, programs/staff for end-of-life care, or beds reserved for hospice residents. Finally, consistent with national averages, FP chain-affiliated (40%) nursing homes are the most common of the 4 ownership/affiliation characteristics. Table 2 presents the findings of the 3 logistic regression models. Model 1, any ADP innovation, reveals that having other innovations— specifically quality-of-life activities (odds ratio [OR], 1.46; confidence interval [CI], 1.10-1.94) and inhouse hospice services (OR, 1.97; CI, 1.35-2.88)— increases the likelihood of offering either a POLST and/or Five Wishes program. Based on these findings, we reject the null for hypothesis 1. The results of model 2 show that having an in-house hospice (OR, 1.87; CI, 1.02-3.45) increased the likelihood of offering the Five Wishes program as did being an NP chain-affiliated nursing home (OR, 2.38; CI, 1.11-5.12). Based on these findings, for model 2, we reject the null for hypothesis 1, but fail to reject the null for hypothesis 2. Finally, similar to the first model, the results of model 3 suggest that the presence of qualityof-life activities (OR, 1.46; CI, 1.07-2.00), in-house hospice (OR, 1.99; CI, 1.32-3.00), and being in a FP freestanding nursing home (OR, 1.85; CI, 1.03-3.33) increased the likelihood of the nursing home offering the POLST program. Similar to model 2, the findings of model 3 lead us to reject the null for hypothesis 1, but fail to reject the null for hypothesis 2.
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Advance Directives Programs in Nursing Homes Table 1. Sample Descriptivesa Mean or Percent Dependent variables Physician Order for Life-Sustaining Treatment Five Wishes Any advance directive programs Nursing home innovations Staffing indicators Medical director has end-of-life training Quality-of-life activities Offers gardening Allows pets Has intergenerational activities Clinical services innovations Clinically intensive services Dialysis-hemo Dialysis-peritoneal Infusion therapy Peripherally inserted central lines Ventilator or pulmonary therapy Bladder scanner Blood transfusions Parenteral nutrition In-house hospice/end-of-life services Special program or staff for hospice Special program or staff for palliative or end-of-life care Beds for hospice Organizational characteristics Not for profit (NP)/independent NP/affiliated For profit (FP)/independent FP/affiliated Potential confounders Registered nurse hours per resident day Percentage of Medicaid residents Percentage of Medicare residents Bed size Occupancy rate
SD
13% 5% 16%
12% 2.51 77% 88% 87% 1.51 3% 11% 43% 22% 9% 9% 7% 48% 31% 19% 17% 6%
0-1 0-1 0-1
0.76
1.54
29% 12% 19% 40% 3.09 3.60 1.59 2.40 3.50
Range
0-1 0-3 0-1 0-1 0-1 0-8 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1
1.17 1.16 0.72 0.81 1.39
1-6 1-5 1-3 1-4 1-5
a
Unweighted sample = 949.
Of the 5 confounding variables, only registered nurse hours per resident day was consistently significant and positively associated with ADP across all 3 models. DISCUSSION As the number of people dying in nursing homes continues to increase, it becomes critical that systems are put in place to ascertain and then honor the wishes of these individuals. Many of the more widely used advance directives often fail to fully reflect the final wishes of a dying person, or health care personnel fail to follow the directive for a variety of reasons.4 Five Wishes and the POLST program offers
hope to individuals who utilize one or the other of these instruments that his/her final wishes will be fulfilled. Although both programs have been nationally available for well over a decade, use among institutional providers lags behind that of other advance directives. Given that prior research has shown variability in ADP use by various organizational characteristics, understanding the factors associated with the use of these types of ADPs within nursing homes may be crucial toward expanding their use.25 The purpose of this project was to explore the relationship of organizational characteristics and service innovations to ADP use. Using data from the NNHS, the study hypothesized that innovative nursing homes and NP/independent
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Abbreviations: CI, confidence interval; OR, odds ratio. Sample size = 949; population size = 13 261. a P .010. b P .05. c P .001. d Referent group: NP/independent.
Nursing home innovations Medical director has end-of-life training Quality-of-life activities Clinically intensive services In-house hospice/end-of-life services Organizational characteristics Not for profit (NP)/affiliatedd For profit (FP)/independentd FP/affiliatedd Potential confounders Registered nurse hours per resident day Percentage of Medicaid residents Percentage of Medicare residents Bed size Occupancy rate 0.61 0.89 0.63
0.94 1.10 0.91 1.35
Lower
0.13 1.17 0.10 0.87 0.17 0.81 0.11 0.64 0.07 0.85 F12,917 = 3.95 Prob. > F = 0.0000
0.35 0.43 0.26
1.13 1.54 1.04 1.40c 1.06 1.11 0.84 0.98
0.38 0.21 0.06 0.38
SE
1.53 1.46a 1.02 1.97c
OR
1.68 1.28 1.50 1.09 1.12
2.07 2.67 1.71
2.50 1.94 1.16 2.88
Upper
95% CI
Model 1: Any Advance Directive Program Innovation
1.11 0.71 0.27
0.81 0.95 0.83 1.02
Lower
0.24 1.28 0.12 0.75 0.30 0.72 0.21 0.65 0.15 0.95 F12,917 = 4.31 Prob. > F = 0.0000
0.93 0.71 0.32
2.38b 1.65 0.68 1.69c 0.96 1.19 0.99 1.21
0.65 0.36 0.11 0.58
SE
1.72 1.52 1.02 1.87b
OR
2.23 1.24 1.96 1.49 1.53
5.12 3.84 1.69
3.62 2.42 1.26 3.45
Upper
95% CI
Model 2: Five Wishes Only
Table 2. Logistic Regression of Presence of Advance Directive Program Innovations
1.25b 1.06 1.06 0.78 0.97
1.00 1.85b 1.32
1.59 1.46b 1.01 1.99a
OR
0.50 1.03 0.76
0.94 1.07 0.88 1.32
Lower
0.12 1.03 0.12 0.85 0.19 0.75 0.11 0.59 0.07 0.84 F12,917 = 2.69 Prob. > F = 0.0014
0.36 0.55 0.36
0.43 0.23 0.07 0.42
SE
1.52 1.32 1.50 1.04 1.13
2.01 3.33 2.27
2.69 2.00 1.16 3.00
Upper
95% CI
Model 3: Physician Order for Life-Sustaining Treatment Program Only
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Advance Directives Programs in Nursing Homes nursing homes would be more likely to offer these ADPs than would other nursing homes. The results show mixed support for these hypotheses. Prior research found that nursing homes that engaged in one type of service innovation would be more likely to engage in others.13,21 Thus, we anticipated that the use of an ADP innovation may be associated with other appropriate staffing and clinical innovations. The findings of the 3 logistic models support this hypothesis. Offering gardening, pets or pet therapy, or intergenerational activities and having an in-house hospice/end-of-life services were associated with an increased likelihood that the nursing home would offer any ADP innovation or the POLST program. The presence of Five Wishes was only associated with having an in-house hospice/end-of-life program. Miller and Han9 also reported that the presence of the Five Wishes program was associated with having specially trained staff for hospice or palliative/end-of-life care. The significance of the in-house measure may suggest that having knowledge and appropriately trained staff—as is necessary for an in-house hospice/end-of-life program—is an integral component for innovativeness in the palliative care market.9 The second hypotheses suggested that independent NP nursing homes would be more likely offer these ADPs than other nursing homes. The finding of the logistic regression models leads us to fail to reject the null hypothesis. Thus, for the Five Wishes model, NP/affiliated and for the POLST program model FP/independent nursing homes were more likely than NP/ independent to offer these ADP. The extant literature on nursing home innovation almost consistently finds that NP nursing homes edge out FP nursing homes when it comes to innovative offerings.9,31 Thus, it may not be surprising that at least one (ie, NP/affiliated) of the 2 types of NP included in the model offered ADPs. However, the research for chain membership is not as direct. Banaszak-Holl et al13 reported that chain affiliated nursing homes were more likely to be innovative than independent providers. However, Castle and Mor,25 Miller and Han,9 and Levy et al26 reported that independent nursing homes were slightly more likely
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than chain nursing homes to use ADP or offer hospice/palliative care. It is important to note that the study of Levy and Fish26 grouped ownership and chain affiliation into categories identical to the ones presented in this study. Extrapolating from the findings on ownership and chain affiliation, one conclusion may be that, among FP providers, independence may allow for greater discretion when it comes to implementing innovative services.32 Nonetheless, additional research is necessary to better tease out the effect of the interaction between ownership and chain affiliation on organizational choices within the nursing home industry. CONCLUSION As several researchers have discovered, the commitment to nursing home innovations needs to be evidenced across multiple levels.27,33-35 This includes both the clinical and top management levels and the structural and process levels. Without resource commitment and investment, innovations may be less effective. And top management is primarily responsible for making decisions on resource commitment for both clinical and nonclinical areas within the nursing home. Thus, having an appropriately trained medical director and, by extension, director of nursing and top administrator may be a crucial component for innovativeness. Furthermore, while the concept of a ‘‘good death’’ may vary between the resident and the institution, representatives of both groups may agree that one component of this is having final wishes honored.2 Implementing appropriate instruments to communicate these wishes is one step toward achieving a good death. Limitations and future research Although the findings of this study fill a gap in the research, the study, nonetheless, has several limitations. First, as a cross-sectional study, we can make no assertions regarding the causal associations between the constructs of interest. However, we can suggest that there is an association between the constructs. Next, although survey data can reveal associations, the information in the data set offers little in
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the way of explanation for these findings. This limitation supports the need for qualitative research exploring differences on the organizational level. Finally, the NNHS presents self-reported data from a nursing home representative. Thus, response bias is possible. However, many of the questions asked are easily verifiable, which limits the likelihood of bias in the responses.
The NNHS remains one of the few nationally representative data sets on nursing home behavior in the United States. Many of the questions from this data set focus on nursing home characteristics not addressed in other national data sets. Therefore, the fact that the data are from 2004 should not limit or diminish the usefulness of these data and the findings.
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14. Castle NG, Banaszak-Holl J. Top management team characteristics and innovation in nursing homes. Computerization of the minimum data set (MDS) in chain and nonchain nursing homes. The Gerontologist. 1997;37:572-580. 15. Schlesinger M, Gray BH. How nonprofits matter in American medicine, and what to do about it. Health Aff. 2006;25:W287-W303. 16. Vitaliano DF. Do not-for-profit firms maximize profit? Q Rev Econ Finance. 2003;43(1):75-87. 17. Bays CW. Why most private hospitals are nonprofit. J Policy Anal Manage. 1983;2(3):366-385. 18. Hansmann HB. Role of nonprofit enterprise. Yale Law J. 1980;89:835-901. 19. Weisbrod BA. The Nonprofit Economy. Cambridge, MA: Harvard University Press; 1988. 20. Dobalian A. Nursing facility compliance with do-nothospitalize orders. Gerontologist. 2004;44(part 2): 159-165. 21. Castle NG. Innovation in nursing homes: which facilities are the early adopters? Gerontologist. 2001; 41(part 2):161-172. 22. Fizel JL, Nunnikhoven TS. The efficiency of nursing home chains. Appl Econ. 1993;25(1):49-55. 23. Knox KJ, Blankmeyer EC, Stutzman JR. Private-pay demand for nursing facilities in a market with excess capacity. Atlantic Econ J. 2006;34(1):75. 24. Zinn JS, Mor V, Castle N, Intrator O, Brannon D. Organizational and environmental factors associated with nursing home participation in managed care. Health Serv Res. 1999;33(6):1753-1767. 25. Castle NG, Mor V. Advance care planning in nursing homes: pre– and post–Patient Self-determination Act. Health Serv Res. 1998;33(1):101-124. 26. Levy CR, Fish R, Kramer A. Do-not-resuscitate and do-not-hospitalize directives of persons admitted to skilled nursing facilities under the Medicare benefit. J Am Geriatr Soc. 2005;53(12):2060-2068. 27. Castle NG, Ferguson JC, Hughes K. Humanism in nursing homes: the impact of top management. J Health Hum Serv Adm. 2009;31(4):483-516. 28. Bruck L. Welcome to Eden... bringing animals and children into nursing homes. Nurs Homes Long Term Care Manage. 1997;46(1):28-33. 29. Raske M. Nursing home quality of life: study of an enabling garden. J Gerontol Soc Work. 2010;53(4): 336-351.
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Advance Directives Programs in Nursing Homes 30. Stahl DA. Development of subacute care services. Nurs Manage. 1994;25(11):32-34. 31. Lee HY. Quality of Care: Impact of Nursing Home Characteristics, San Francisco, CA: University of California; 2009:182. 32. Kruzich JM. Ownership, chain affiliation, and administrator decision-making autonomy in long-term care facilities. Adm Soc Work. 2005;29(1):5-24. 33. Anderson RA, Issel LM, McDaniel RR Jr. Nursing homes as complex adaptive systems: relationship
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The Use of Innovative Advance Directives Programs in Nursing Homes Jullet A. Davis, PhD End-of-life service providers continue to seek improved instruments for individuals to convey their last wishes. Two such instruments are Five Wishes and Physician Order for Life-Sustaining Treatment. This project explores the relationship of nursing home profit status and innovativeness to the use of these advance directive programs (ADPs). The specific aims of this study were to determine what other types of innovations are associated with the use of these ADPs and the differences in use by nursing home characteristics. Data for this project come from the 2004 National Nursing Home Survey (n = 949). The data were analyzed using 3 logistic regression models. The results revealed that quality-of-life activities, having an in-house hospice, being a notfor-profit chain-affiliated nursing home, or a for-profit freestanding nursing home were all associated with ADP. These results suggest that ADP use may be influenced by nursing home characteristics other than clinical services. Key words: end-of-life care, hospice, innovations, nursing homes, profit status
S RESEARCH AND practitioners alike continue to struggle with developing and defining the factors associated with a ‘‘good death,’’ most would agree that the communicating and honoring of a person’s final wishes are an integral component toward achieving this goal.1,2 The passage of the Patient Self-determination Act of 1990 made it mandatory that health care providers, including nursing homes, receiving Medicaid and Medicare reimbursement inform residents at the time of admission of their rights to express their final wishes using an advance directive.3 Currently, the popular instruments used to convey final wishes are as living wills, do-not-resuscitate, health care proxies, durable power of attorney, and do-not-hospitalize orders.
A
Author Affiliation: Management Department; and Center for Mental Health and Aging, The University of Alabama, Tuscaloosa, Alabama. The author has no conflicts of interest. Correspondence: Jullet A. Davis, PhD, Management Department, The University of Alabama, Box 870225, Tuscaloosa, AL 35487 ([email protected]). DOI: 10.1097/HCM.0b013e3182a9d6d2
Yet, these instruments face numerous limitations in that they may not fully reflect the nuances of a person’s wishes (for instance, who should be present with the patient), or providers (such as paramedics) may fail to enforce these directives.4 The limitations of the more traditional instruments suggest there is room for new methods by which patients can communicate their final wishes and have those wishes honored. DESCRIPTION OF THE PROBLEM Five Wishes and the Physician Order for LifeSustaining Treatment (POLST) paradigm program may each represent an innovation in advance directive programs (ADPs) in that they either attempt to address final wishes comprehensively or they are directed to providers, which may increase the likelihood of compliance.5 The POLST paradigm program documents final wishes in the form of medical orders.6 The POLST guides the treatment decisions of all medical personnel including emergency medical technicians, physicians, and nurses. Physician Order for Life-Sustaining Treatment is in use in 16 states, with another 27 states developing programs (Figure 1). Five Wishes, on
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Advance Directives Programs in Nursing Homes
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Figure 1. States with POLST Paradigm Programs. Source: Center for Ethics in Health Care, Oregon Health & Science University, 2013.
the other hand, addresses the individual’s wishes in 5 distinct areas: (1) the appointment of a surrogate decision maker, (2) the kind of medical treatment desired or not, (3) the level of comfort, (4) how people should treat the patient, and (5) what information should be shared with loved ones.7 ‘‘Five Wishes meets the legal requirements in 42 states (Figure 2) . . .’’ but may be used as a guide for writing an advance directive in all 50 states (Aging With Dignity,7 para. 1). STUDY PURPOSE Resnick and Foster,5 Resnick,8 and Miller and Han9 presented data from the National Nursing Home Survey (NNHS) on the trends in the presence of 1 or more of the ADP instruments noted above. Although these data help us to understand the scope of the
utilization of these instruments, it remains unclear what factors are associated with the use of the ADPs of interest. The specific aims of this study were to determine: (1) what other types of end-of-life innovations are associated with the use of these unique ADPs and (2) differences in ADP use by nursing home organizational characteristics. Nursing home innovation Rowe and Boise10(p6) defined organizational innovation as ‘‘the successful utilization of processes, programs, or products which are new to an organization and which are introduced as a result of decisions made within that organization.’’ In a later piece, they noted that an organization is innovative only if the processes, programs, or products are implemented in advance of an external market demand.11 Thus, rarity (as well as timing) is an integral feature
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Figure 2. States with Five Wishes programs. Source: Aging With Dignity,7 2012.
of innovation. Given that the oldest of the 2 ADPs of interest, POLST, was established in the mid-1990s, and that as of 2003, only approximately 13% of nursing home residents have 1 or more of these ADPs, it may be reasonable to assert that these ADPs may represent a new innovation in end-of-life care.5,12 Some researchers found that nursing homes that are innovative in one service area may also be innovative in others.13,14 The innovativeness of a nursing home may be associated with benefits in resident outcomes. Thus: Hypothesis 1: Nursing homes that offer other innovations will be more likely to offer 1 or more ADPs than will noninnovative nursing homes. Ownership status and chain affiliation There are numerous theoretical and empirical studies in the management and health care literature addressing the motivating principles guiding not-for-profit (NP) behaviors.15,16 According to the seminal theories of Bays,17 Hansmann,18 and Weisbrod,19 NP firms differ from for-profit (FP) firms along 3 key dimensions. First, NP firms offer services that the market may not offer given the cost of the services or the nature of the service. Second, NP firms may focus on aspects or qualities of a service that FP firms may fail to adequately address. Finally, the motivations of NP firms may differ from that of FP firms, thus ensuring that criteria other than profits are a vital component
of service development. This key difference between NP and FP firms is evident within the nursing home industry given variations in service provision by facility ownership. For example, Dobalian20 reported that residents living in NP nursing homes were more likely than residents living in FP nursing homes to have a living will. However, a key moderator of ownership may be membership in a multifacility chain. Researchers have found that the benefits of membership in a multifacility chain may allow nursing homes better access to additional resources, knowledge, skills, shared labor costs, and various care technologies.21-24 Thus, chainaffiliated nursing homes may be better positioned to take full advantage of care innovations.21 However, much of the research exploring chain membership and the use of ADPs found either no relationship or greater use by independent facilities.9,20,25 Nonetheless, the study of Levy et al26 suggests that the interaction of ownership and chain membership may yield more fruitful findings. Their study found that residents residing in NP independent nursing homes were more likely to have a do-not-resuscitate or a do-not-hospitalize order than residents in FP chain or FP independent nursing homes. Based on the prior findings, it is likely that: Hypothesis 2: Nursing homes operated as independent NP facilities are more likely to use ADPs than any other category of facilities.
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Advance Directives Programs in Nursing Homes METHODS Sample Data for this project come from the 2004 NNHS. This data set is used as it remains the only nationally available sample documenting the presence of the POLST Program and Five Wishes in nursing home setting. The NNHS is a publicly available series of nationally representative surveys of nursing homes across the nation and includes information on the services, staff, and residents of these homes. The sampling process consisted of a stratified 2-stage probability design. In the first stage, facilities were stratified by bed size and metropolitan area. Within these strata, facilities were then grouped by certification status, hospital-based or freestanding, ownership, geographic region, state, county, and zip code. Next, individual facilities were chosen using systematic sampling with probability proportional to the number of facility beds. Using this method, 1500 nursing homes were selected and contacted; a total of 1174 nursing homes chose to participate in the survey. The sampling process was designed to allow for generalization back to the entire population of nursing homes (16 000). After removing observations with missing data, the final sample for this study consisted of 949 nursing homes (weighted sample = 13 261). The project was approved by the institutional review board of the University of Alabama (IRB# EX-12-CM-049).
Variables Dependent variables The dependent variable is a sum of the 2 ADPs: POLST Program and Five Wishes. The NNHS asks respondents: ‘‘Does this facility participate in the following End-of-Life Programs?’’ The response options were dichotomous (yes/no). Three dependent variables were created. The first measures the use of either POLST or Five Wishes. The next 2 dependent variables measure POLST and Five Wishes individually.
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Independent variables Several independent variables were included to measure various organizational factors that categorize nursing home innovations, ownership, and chain affiliation. Nursing Home Innovations. Innovation is operationalized using several measures designed to capture staffing, quality of life, and clinical service innovations. The first variable comes from a survey question that asks if the medical director has advanced education in palliative/end-of-life care. Castle et al27 argue that top managers, which may include the medical director, are instrumental in guiding the behaviors of their respective nursing homes. This was a dichotomous measure, with yes coded as 1. The next variable captures activities associated with resident quality-of-life innovations. The 3 variables chosen from the NNHS have each been shown by other research to improve resident quality of life.28,29 The NNHS asked respondents if they offered gardening, pets or pet therapy, or intergenerational activities. The number of ‘‘yes’’ responses was summed. Clinical service innovations represent the nursing home’s venture into subacute services and hospice care, which requires a great deal of expertise.30 The service choices are dialysis-hemo, dialysis-peritoneal, infusion therapy, peripherally inserted central lines, ventilator/pulmonary therapy, bladder scanner, blood transfusions, and parenteral nutrition. The responses were summed to capture the total number of care innovations offered by each nursing home. The in-house hospice question is composed of 3 questions from the survey. The questions ask respondents if there are clusters of beds for hospice, special program/staff for hospice, and special program/ staff for palliative/end of life. The 3 questions were summed and then dichotomized to capture the percentage of nursing homes that offer on-site hospice care. Ownership and chain affiliation The NNHS categorizes nursing home ownership as either FP or all others. The all-other category includes private and government NP nursing home. Chain membership is a dichotomous
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variable with the choice of either chain member or freestanding (independent). Using these 2 variables, ownership and chain affiliation, 4 dichotomous variables were created, with each representing a unique combination, NP/ independent, NP/affiliated, FP/independent, and FP/affiliated.
Potential confounders As the decision to offer these types of ADPs may be affected by factors other than innovation and ownership, additional potential confounders were included in the model. The analysis included controls for the presence of registered nurses, Medicaid, Medicare, the number of beds, and occupancy rate. For each of these variables, the NNHS recoded the actual percent into groups; therefore, the actual percentage for each is not given in the data set. The number of registered nurse hours adjusted by resident days was collapsed across 6 categories: 1 = 0 to 0.125, 2 = 0.125 to 0.24, 3 = 0.25 to 0.49, 4 = 0.5 to .99, 5 = 1 to 1.99, and 6 = 2 or more. The percentage of residents with Medicaid as the primary payment source was aggregated into 5 categories: 1 = 0% to 19%, 2 = 20% to 39%, 3 = 40% to 59%, 4 = 60% to 79%, and 5 = 80% or more. The Medicare as primary payment source was aggregated differently, with 1 = 0% to 9%, 2 = 10%% to 19%, and 3 = 20% or more. The number of beds in the nursing home was grouped as follows: 1 = 3 to 49, 2 = 50 to 99, 3 = 100 to 199, and 4 = 200+ beds. Finally, occupancy rate was grouped into categories: 1 = less than 70%, 2 = 70% to 79%, 3 = 80% to 89%, 4 = 90% to 94%, and 5 = 95% or more.
Data analysis The SVYSET option in Stata version 12 was used, which accounts for the multistage probability design of the NNHS. The data were analyzed using logistic regression. Three separate models are presented. In the first, the use of any ADP was examined. The second and third models analyzed Five Wishes and POLST program, respectively.
FINDINGS The sample characteristics reveal that approximately 16% of nursing homes participated in the POLST program or Five Wishes (Table 1). When it comes to staffing, 12% of nursing homes reported having a medical director with some form of palliative or end-of-life training. Nursing homes reported having gardening, pets or pet therapy, and intergenerational activities (mean, 2.51 [SD, 0.76]). However, few nursing homes offer more than 2 (mean, 1.51 [SD, 1.54]) of the clinical services listed in the NNHS, with parenteral nutrition (mean, 48%) followed by infusion therapy (mean, 43%) the most commonly offered. More than 31% reported having either special programs/staff for hospice, programs/staff for end-of-life care, or beds reserved for hospice residents. Finally, consistent with national averages, FP chain-affiliated (40%) nursing homes are the most common of the 4 ownership/affiliation characteristics. Table 2 presents the findings of the 3 logistic regression models. Model 1, any ADP innovation, reveals that having other innovations— specifically quality-of-life activities (odds ratio [OR], 1.46; confidence interval [CI], 1.10-1.94) and inhouse hospice services (OR, 1.97; CI, 1.35-2.88)— increases the likelihood of offering either a POLST and/or Five Wishes program. Based on these findings, we reject the null for hypothesis 1. The results of model 2 show that having an in-house hospice (OR, 1.87; CI, 1.02-3.45) increased the likelihood of offering the Five Wishes program as did being an NP chain-affiliated nursing home (OR, 2.38; CI, 1.11-5.12). Based on these findings, for model 2, we reject the null for hypothesis 1, but fail to reject the null for hypothesis 2. Finally, similar to the first model, the results of model 3 suggest that the presence of qualityof-life activities (OR, 1.46; CI, 1.07-2.00), in-house hospice (OR, 1.99; CI, 1.32-3.00), and being in a FP freestanding nursing home (OR, 1.85; CI, 1.03-3.33) increased the likelihood of the nursing home offering the POLST program. Similar to model 2, the findings of model 3 lead us to reject the null for hypothesis 1, but fail to reject the null for hypothesis 2.
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Advance Directives Programs in Nursing Homes Table 1. Sample Descriptivesa Mean or Percent Dependent variables Physician Order for Life-Sustaining Treatment Five Wishes Any advance directive programs Nursing home innovations Staffing indicators Medical director has end-of-life training Quality-of-life activities Offers gardening Allows pets Has intergenerational activities Clinical services innovations Clinically intensive services Dialysis-hemo Dialysis-peritoneal Infusion therapy Peripherally inserted central lines Ventilator or pulmonary therapy Bladder scanner Blood transfusions Parenteral nutrition In-house hospice/end-of-life services Special program or staff for hospice Special program or staff for palliative or end-of-life care Beds for hospice Organizational characteristics Not for profit (NP)/independent NP/affiliated For profit (FP)/independent FP/affiliated Potential confounders Registered nurse hours per resident day Percentage of Medicaid residents Percentage of Medicare residents Bed size Occupancy rate
SD
13% 5% 16%
12% 2.51 77% 88% 87% 1.51 3% 11% 43% 22% 9% 9% 7% 48% 31% 19% 17% 6%
0-1 0-1 0-1
0.76
1.54
29% 12% 19% 40% 3.09 3.60 1.59 2.40 3.50
Range
0-1 0-3 0-1 0-1 0-1 0-8 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1 0-1
1.17 1.16 0.72 0.81 1.39
1-6 1-5 1-3 1-4 1-5
a
Unweighted sample = 949.
Of the 5 confounding variables, only registered nurse hours per resident day was consistently significant and positively associated with ADP across all 3 models. DISCUSSION As the number of people dying in nursing homes continues to increase, it becomes critical that systems are put in place to ascertain and then honor the wishes of these individuals. Many of the more widely used advance directives often fail to fully reflect the final wishes of a dying person, or health care personnel fail to follow the directive for a variety of reasons.4 Five Wishes and the POLST program offers
hope to individuals who utilize one or the other of these instruments that his/her final wishes will be fulfilled. Although both programs have been nationally available for well over a decade, use among institutional providers lags behind that of other advance directives. Given that prior research has shown variability in ADP use by various organizational characteristics, understanding the factors associated with the use of these types of ADPs within nursing homes may be crucial toward expanding their use.25 The purpose of this project was to explore the relationship of organizational characteristics and service innovations to ADP use. Using data from the NNHS, the study hypothesized that innovative nursing homes and NP/independent
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Abbreviations: CI, confidence interval; OR, odds ratio. Sample size = 949; population size = 13 261. a P .010. b P .05. c P .001. d Referent group: NP/independent.
Nursing home innovations Medical director has end-of-life training Quality-of-life activities Clinically intensive services In-house hospice/end-of-life services Organizational characteristics Not for profit (NP)/affiliatedd For profit (FP)/independentd FP/affiliatedd Potential confounders Registered nurse hours per resident day Percentage of Medicaid residents Percentage of Medicare residents Bed size Occupancy rate 0.61 0.89 0.63
0.94 1.10 0.91 1.35
Lower
0.13 1.17 0.10 0.87 0.17 0.81 0.11 0.64 0.07 0.85 F12,917 = 3.95 Prob. > F = 0.0000
0.35 0.43 0.26
1.13 1.54 1.04 1.40c 1.06 1.11 0.84 0.98
0.38 0.21 0.06 0.38
SE
1.53 1.46a 1.02 1.97c
OR
1.68 1.28 1.50 1.09 1.12
2.07 2.67 1.71
2.50 1.94 1.16 2.88
Upper
95% CI
Model 1: Any Advance Directive Program Innovation
1.11 0.71 0.27
0.81 0.95 0.83 1.02
Lower
0.24 1.28 0.12 0.75 0.30 0.72 0.21 0.65 0.15 0.95 F12,917 = 4.31 Prob. > F = 0.0000
0.93 0.71 0.32
2.38b 1.65 0.68 1.69c 0.96 1.19 0.99 1.21
0.65 0.36 0.11 0.58
SE
1.72 1.52 1.02 1.87b
OR
2.23 1.24 1.96 1.49 1.53
5.12 3.84 1.69
3.62 2.42 1.26 3.45
Upper
95% CI
Model 2: Five Wishes Only
Table 2. Logistic Regression of Presence of Advance Directive Program Innovations
1.25b 1.06 1.06 0.78 0.97
1.00 1.85b 1.32
1.59 1.46b 1.01 1.99a
OR
0.50 1.03 0.76
0.94 1.07 0.88 1.32
Lower
0.12 1.03 0.12 0.85 0.19 0.75 0.11 0.59 0.07 0.84 F12,917 = 2.69 Prob. > F = 0.0014
0.36 0.55 0.36
0.43 0.23 0.07 0.42
SE
1.52 1.32 1.50 1.04 1.13
2.01 3.33 2.27
2.69 2.00 1.16 3.00
Upper
95% CI
Model 3: Physician Order for Life-Sustaining Treatment Program Only
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Advance Directives Programs in Nursing Homes nursing homes would be more likely to offer these ADPs than would other nursing homes. The results show mixed support for these hypotheses. Prior research found that nursing homes that engaged in one type of service innovation would be more likely to engage in others.13,21 Thus, we anticipated that the use of an ADP innovation may be associated with other appropriate staffing and clinical innovations. The findings of the 3 logistic models support this hypothesis. Offering gardening, pets or pet therapy, or intergenerational activities and having an in-house hospice/end-of-life services were associated with an increased likelihood that the nursing home would offer any ADP innovation or the POLST program. The presence of Five Wishes was only associated with having an in-house hospice/end-of-life program. Miller and Han9 also reported that the presence of the Five Wishes program was associated with having specially trained staff for hospice or palliative/end-of-life care. The significance of the in-house measure may suggest that having knowledge and appropriately trained staff—as is necessary for an in-house hospice/end-of-life program—is an integral component for innovativeness in the palliative care market.9 The second hypotheses suggested that independent NP nursing homes would be more likely offer these ADPs than other nursing homes. The finding of the logistic regression models leads us to fail to reject the null hypothesis. Thus, for the Five Wishes model, NP/affiliated and for the POLST program model FP/independent nursing homes were more likely than NP/ independent to offer these ADP. The extant literature on nursing home innovation almost consistently finds that NP nursing homes edge out FP nursing homes when it comes to innovative offerings.9,31 Thus, it may not be surprising that at least one (ie, NP/affiliated) of the 2 types of NP included in the model offered ADPs. However, the research for chain membership is not as direct. Banaszak-Holl et al13 reported that chain affiliated nursing homes were more likely to be innovative than independent providers. However, Castle and Mor,25 Miller and Han,9 and Levy et al26 reported that independent nursing homes were slightly more likely
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than chain nursing homes to use ADP or offer hospice/palliative care. It is important to note that the study of Levy and Fish26 grouped ownership and chain affiliation into categories identical to the ones presented in this study. Extrapolating from the findings on ownership and chain affiliation, one conclusion may be that, among FP providers, independence may allow for greater discretion when it comes to implementing innovative services.32 Nonetheless, additional research is necessary to better tease out the effect of the interaction between ownership and chain affiliation on organizational choices within the nursing home industry. CONCLUSION As several researchers have discovered, the commitment to nursing home innovations needs to be evidenced across multiple levels.27,33-35 This includes both the clinical and top management levels and the structural and process levels. Without resource commitment and investment, innovations may be less effective. And top management is primarily responsible for making decisions on resource commitment for both clinical and nonclinical areas within the nursing home. Thus, having an appropriately trained medical director and, by extension, director of nursing and top administrator may be a crucial component for innovativeness. Furthermore, while the concept of a ‘‘good death’’ may vary between the resident and the institution, representatives of both groups may agree that one component of this is having final wishes honored.2 Implementing appropriate instruments to communicate these wishes is one step toward achieving a good death. Limitations and future research Although the findings of this study fill a gap in the research, the study, nonetheless, has several limitations. First, as a cross-sectional study, we can make no assertions regarding the causal associations between the constructs of interest. However, we can suggest that there is an association between the constructs. Next, although survey data can reveal associations, the information in the data set offers little in
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the way of explanation for these findings. This limitation supports the need for qualitative research exploring differences on the organizational level. Finally, the NNHS presents self-reported data from a nursing home representative. Thus, response bias is possible. However, many of the questions asked are easily verifiable, which limits the likelihood of bias in the responses.
The NNHS remains one of the few nationally representative data sets on nursing home behavior in the United States. Many of the questions from this data set focus on nursing home characteristics not addressed in other national data sets. Therefore, the fact that the data are from 2004 should not limit or diminish the usefulness of these data and the findings.
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