Effect of Do-Not-Resuscitate Orders on Hospitalization of Nursing Home Residents Evaluated for Lower Respiratory Infections

Steven C. Zweig, Robin L. Kruse, Ellen F. Binder, Kristina L. Szafara, David R. Mehr

Research output: Contribution to journalArticlepeer-review

63 Scopus citations


OBJECTIVES: To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs). DESIGN: Prospective cohort. SETTING: Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study. PARTICIPANTS: NH residents with a LRI (n = 1031). MEASUREMENTS: Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed. RESULTS: Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio = 0.69, 95% confidence interval = 0.49-0.97). CONCLUSION: DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.

Original languageEnglish
Pages (from-to)51-58
Number of pages8
JournalJournal of the American Geriatrics Society
Issue number1
StatePublished - Jan 2004


  • Advance care directives
  • Do not resuscitate
  • Hospitalization
  • Nursing home residents
  • Propensity score


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