Nursing Home Residents with Mental Illness Less Likely to have Advance Care Directives

Researchers examining a national sample of more than 13,500 nursing home residents found that those with serious mental illness were 24% less likely to have any advance care directives compared to residents without mental illness, according to a study in the American Psychiatric Association’s journal Psychiatric Services.

Advance care plans allow nursing home residents to make informed choices about their future treatment or identify a proxy for healthcare decisions if they become too ill to make decisions.

Researchers looked at four types of advance plans made by residents in 1,174 nursing homes: living wills; do-not-resuscitate orders; do-not hospitalize orders; and orders concerning restriction of feeding tubes, medication, or other treatments. Overall, 68% of residents without mental illness had at least one of the four types of plan, compared with 57% of those with serious mental illness (schizophrenia or another psychotic disorder or bipolar disorder). In addition, the rate of having each type of advance plan was lower among those with mental illness.

The researchers noted that given the relatively high prevalence of serious mental illness in nursing homes and the high level of associated physical disability and medical comorbidities, “nursing home residents with serious mental illness are likely to represent a group of high priority for implementing advance directives.”

“Our findings reflect disparities in medical decision making caused by such factors as provider bias rather than actual differences in expressed care preferences,” the researchers said. They also noted that nursing home care is typically focused on management of chronic medical conditions and functional disabilities and that staff often do not have much training in mental health issues.

The researchers suggest further research to understand factors underlying the lack of advance care plans among some residents with mental illness, including individual factors, such as inappropriate behaviors and impaired communication skills; and provider factors, such as training, experience, and attitude.

The study authors are affiliated with the University of Iowa and with Iowa City Veterans Affairs Medical Center.

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Study: Origination of Medical Advance Directives Among Nursing Home Residents With and Without Serious Mental Illness

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