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“Do Not Hospitalize” Orders

An article by Elizabeth Gray

A recent article by Judith Graham “The New Old Age, A Misunderstood Directive,” New York Times, 20 November, 2013, got me thinking about “Do Not Hospitalize” orders.

A lot of people do not know what a “Do Not Hospitalize” order is and how one is used.  As attorneys we routinely put such orders in our advance directives without a detailed explanation to our clients.  What is a “Do Not Hospitalize” order? Would your health care decision makers (“proxies”) know how to use one?

In a recent publication, doctors conducted a study to determine how well the health care proxies understood these orders and whether to initiate them or not: “Do-Not-Hospitalize Orders for Individuals with Advanced Dementia: Healthcare Proxies’ Perspectives.”  The study was conducted on health care proxies for patients with advanced dementia.  The doctors found that the problem with the DNH orders is that most people are confused about what a DNH does and how to use one.  In the study, most of the proxies thought the DNH order meant “do not treat.”  The other problem had to do with doctors communicating sufficient information to the health care proxies for an informed decision to be made.  J AM Geriatr Soc 61:1568-1573, 2013.

For seniors suffering from advanced dementia or any individual suffering from a serious illness, a trip to the hospital can cause other major complications.  For example, you may have to go to the hospital to treat an infection and then contract something more serious.  If you stayed at home or in the facility, you could be treated and/or offered comfort care instead.  That is the purpose of the DNH, to allow nature to take its course, with appropriate palliative care, rather than a trip to the hospital.

In order to understand a DNH better, let’s go over the main health care decision making document: the Advance Directive.

An Advance Directive is a document by which you appoint someone to make health care decisions (your “proxy”) for you.  The document usually includes a “living will” which includes instructions to your doctor about treatment preferences and life-sustaining procedures, a “Do Not Resuscitate” order (“DNR”), and your decision on organ donations.  Often, this document includes a Do Not Hospitalize order (“DNH”).

There are 2 types of DNH orders: 1) one is an absolute prohibition against hospitalization under any circumstances; and 2) a general recommendation to avoid hospitalization, but allowing the health care proxy to make the decision on a case by case basis.

Both are acceptable, but if the proxy does not understand what a DNH is and the doctor does not explain the options to the proxy, the frail individual may have to go through an unnecessary hospitalization, the possibility of contracting something more serious at the hospital, and ultimately a poor quality end of life.

There are advantages to hospitalization.  In the hospital, doctors may be able to quickly diagnose and treat painful or dangerous conditions.  In addition, there are specialists and highly technical diagnostic tools available to use on the patient.  At the hospital, a patient can get a blood transfusion or have an operation.  Of course, the disadvantages of hospitalization are that the doctors and staff could misunderstand the patient, the patient’s speech, or misinterpret facial expressions and/or body movements.  There is also a greater risk of infection, increased use of sedating medications and, for a lot of patients, unfamiliar surroundings that cause anxiety.

The key to contemplating using a DNH order is whether the burden of hospitalization overwhelms any potential benefit.  In order for the proxy to make such a decision, the proxy needs to have discussions with the patient and the patient’s doctors.  This will only happen if the patient understands the role of a DNH in his or her care.