Advance Directives and Care Received by Older Nursing Home Residents.

The sample was small, so the authors could not adjust for other factors that might explain differences between groups. Only 78 of the 90 enrolled residents with indwelling devices had documented advance directives and were analysed. Advance directives were recorded only at enrollment, and residents or surrogates could have changed their preferences during follow-up. The directive content was not verified directly with residents or durable power of attorney holders. Residents without documented directives were excluded, and some may have been treated as full code by default facility policy. All residents had an indwelling urinary catheter or feeding tube, so findings may not apply to nursing home residents without devices. Follow-up was short for many residents, with 55 followed for less than 3 months. The study did not capture why residents were transferred to hospital, so it cannot show whether transfers were wanted, unavoidable, or due to changed goals.

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Do not conclude that comfort-oriented directives reliably prevent hospital transfer. In this small observational analysis, comfort-oriented residents still had transfers, and their transfer rate was not significantly lower than usual-care residents.