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” (DNH) orders.
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?
“Do-Not-Hospitalize Orders for Individuals with Advanced Dementia: Healthcare Proxies’ Perspectives,” recently published in the Journal of the American Geriatrics Society, reports that most people are confused about what a DNH does and how to use one. Most of the proxies involved in the cited study 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.
A trip to the hospital can cause complications for seniors with advanced dementia or any other individual suffering from a major illness. For example, during the course of a hospital visit to treat an infection, they could contract something more serious. An alternative is to treat them and/or offer comfort care at home or in the long-term care facility where they are currently residing. That is the purpose of the DNH, to allow nature to take its course, with appropriate palliative care, rather than to subject the individual to hospitalization.
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 DNH.
There are two types of DNH orders. One is an absolute prohibition against hospitalization under any circumstances. The other is a general recommendation to avoid hospitalization that allows 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 poor quality at 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’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.