"Do not resuscitate" (DNR) orders have not been as effective as hoped for every patient who has one. The emotion of the moment, family conflict and confusion are too often the cause.

There are unnecessary costs associated with everyone involved, but more importantly, the patients' wishes for their end-of-life care are not being honored or respected.

A less-common order to not hospitalize patients may be more effective at accomplishing a patient's intended goals. A recent study conducted by researchers at the University of Albany (UAlbany) finds "do not hospitalize" orders can help reduce hospital stays and emergency department visits. Unfortunately, only a small portion of the nursing home residents studied had a DNH order included in their advance directives.

Researchers at UAlbany's School of Public Health conducted a cross-sectional study of residents in New York State skilled nursing facilities. They found that while 61 percent of nursing home residents had DNR orders, 12 percent had feeding restrictions and only 6 percent had DNH orders in place.

The residents with DNH orders had significantly fewer unnecessary hospital stays and emergency department visits in their last 90 days of life than residents without them. They also found the orders helped reduce hospital stays for residents with dementia, but not emergency visits.

"The findings suggest that residents' end-of-life care decisions were respected and honored," said Yuchi Young, UAlbany Associate Professor of Health Policy, Management and Behavior. "Efforts should be made to encourage nursing home residents to complete DNH orders to promote integration of the resident's values and goals in guiding care provision toward the end of life."

As with DNR orders, those for DNH need to be written in a thoughtful and careful way to avoid confusion. Both should be included in the patient's advance directives and clearly specify whether it is "for any reason," or in what circumstances a trip to the hospital is acceptable.

In some cases, hospital services might be desired by the patient or deemed a comfort measure of the end-of-life care.

For example, an Alzheimer's patient with a suspected infection or gallstones may desire treatment for these conditions if they arise. Or stabilizing a wrist fracture for an individual with end-stage renal disease might be needed to make the patient more comfortable and minimize pain.

Honoring the decisions of those at the end of their life is a sign of respect, and the right thing to do for both health professionals and family. This includes respecting their wishes against heroic measures, life-saving interventions and the disruption caused by unnecessary and unwanted trips to the hospital or emergency room.

Sometimes the best care provided is not doing harm by supporting individual wishes.

Resource: National Hospice and Palliative Care Association, Listing of Advance Directives (state-by-state)