Objective: To determine the prevalence of advance directives and do-not-resuscitate (DNR) orders in nursing homes and to measure the effect of the Patient Self-Determination Act (PSDA) and patient characteristics on these prevalences.
Design: Cross-sectional study.
Setting: Eight rural community nursing facilities.
Participants: Six hundred forty-one records of nursing home residents (total census of eight facilities).
Results: The mean age of the residents was 82.6 years and 75% were women. Thirty-seven percent were judged to have decisional capacity. Less than one third of the records revealed an advance directive (standard living will, 11.5%; other written directive, 11.1%; durable power of attorney for health care, 12%). Thirty-six percent had DNR orders. Residents with advance directives were older than those without them. Those residents with advance directives were more likely to have been admitted to the nursing home after the enactment of the PSDA (25.1% before vs 37.9% after enactment; P < .0001). There was substantial variation among facilities in both prevalences. Written rationales for DNR orders were found in only 40% of records.
Conclusion: Enactment of the PSDA reflects increased interest in documentation of advance directives. However, in many nursing facilities, the prevalence of advance directives and DNR orders is relatively low. A greater commitment will be required by providers, residents, and their proxies if we are to change this reality.