Journal of the American Geriatrics Society
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Randomized Controlled Trial Clinical Trial
The effect of do-not-resuscitate orders on physician decision-making.
The effect of do-not-resuscitate (DNR) orders on physicians' decisions to provide life-prolonging treatments other than cardiopulmonary resuscitation (CPR) for patients near the end of life was explored using a cross-sectional mailed survey. Each survey presented three patient scenarios followed by 10 treatment decisions. Participants were residents and attending physicians who were randomly assigned surveys in which all patient scenarios included or did not include a DNR order. ⋯ In some scenarios, the presence of a DNR order was associated with a decreased willingness to draw blood cultures (91% vs 98%, P =.038), central line placement (68% vs 80%, P =.030), or blood transfusion (75% vs 87%, P =.015). The presence of a DNR order may affect physicians' willingness to order a variety of treatments not related to CPR. Patients with DNR orders may choose to forgo other life-prolonging treatments, but physicians should elicit additional information about patients' treatment goals to inform these decisions.
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Randomized Controlled Trial Clinical Trial
Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors.
Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection. ⋯ The association between RN turnover and both outcomes underscores the relationship between nursing leadership and quality of care in these settings. The relationship between hospitalization for infection and for-profit ownership and chain affiliation could reflect policies not to treat acute illnesses in house. The link between social factors of care (environmental quality, prioritizing staff satisfaction, resident privacy, and facility visitation) and hospitalization indicates that a nonmedical model of care may not jeopardize, and may in fact benefit, health-related outcomes. All of these facility characteristics may be modifiable, may affect healthcare costs, and may hold promise for other, less-medical, forms of residential long-term care.
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To systematically explore nursing home (NH) resident and staff attitudes that serve as barriers to detection and management of persistent pain. ⋯ These findings suggest that, if residents' fears regarding addiction, worsening dependence, and the immutable nature of persistent pain were quelled, and if CNAs could feel that adequate time is available for pain assessment, perhaps improved pain management in the NH would result.