When To Consider “Do Not Admit To Hospital”

What does a “Do Not Admit To Hospital” (DNATH) mean?
A “DNATH” order means a resident will not be admitted to the hospital for any reason (although, depending on the situation, there could be exceptions, jointly determined by the family and doctor).  However, a resident could be sent just to the emergency room for something like a laceration which will not quit bleeding and needs to be sutured.

Why and when should you consider a “DNATH” order?

This order is dependent on the ‘goals of care’ for that elder:  is the goal to live as long as possible regardless of the pain or cost; is it to maintain the current level of function (doing the same daily activities) which a surgical procedure or treatment in hospital might help; or, is it to be kept as comfortable as possible and do nothing which may worsen or prolong suffering?  (See the handout Goal Focused Care)

If the goal is to live as long as possible, then certainly the resident would be transferred to hospital for attempted resuscitation if her heart stopped, for any necessary surgery, or for any other treatment not available at Glenwood, such as pneumonia not responding to antibiotics. 

If the goal is to maintain function, then an admission may be appropriate but the decision should be based on the risks and benefits to that resident.  
However, if the goal is comfort only – as when an elder suffers from dementia, or has chronic pain and has decided death is “not an enemy” – then the family is encouraged to request a DNATH. 

What is so bad about sending an elder to be admitted?  Why shouldn’t she go?
Over 70% of our residents have dementia (see handout Dementia: what choices do your have?) and a hospital admission (any change of location) makes the confusion worse and often accelerates their decline.  Our staff, because they are more familiar with the elder’s habits, act as an extended family and provide generally more appropriate care, which is less invasive and less upsetting to a resident. 

For example, for most acute illnesses such as pneumonia, congestive heart failure, various infections, even some heart attacks, our staff can provide appropriate care.  We can start ‘IV’ fluids and antibiotics.   And for those who have dementia and suffer a hip fracture, we have found they do better with a week of bedrest and pain control, rather than going to hospital to have it repaired.

Finally, the American Medical Directors Association (for nursing homes) discourages facilities and their physicians from admitting residents to hospital.
In summary, it’s important that the resident and family clarify their goals and then reach a decision.  Ultimately, we all must do what is in the best interests of our senior.

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