June 2, 2016 About three-quarters (76%) of Canadian long-term care residents have a directive to not be resuscitated if they stop breathing or if their heart stops, and a new report shows that this directive is almost always followed in hospital settings.

According to A Snapshot of Advance Directives in Long-Term Care: How Often Is “Do Not” Done?, released by the Canadian Institute for Health Information (CIHI), about 1 in 2,500 long-term care residents with a do-not-resuscitate (DNR) directive received resuscitation in an acute care hospital after being transferred there for treatment. This indicates that the directive appears to be communicated well among care facilities and understood by care providers.

The story is less clear for do-not-hospitalize (DNH) directives, which come into effect when patients are unable to make this decision about their health care. About 1 in 5 (21%) long-term care residents in this study had an advance directive to not be hospitalized, and about 7% (or 1 in 14) of these residents were admitted to an acute care hospital over the course of the study period.

In some cases, the transfer to hospital may have been appropriate if agreed to by a mentally competent resident or a substitute decision-maker. Supporting this, the study found that

  • Residents with a DNH directive who were physically or mentally healthier were more likely to be admitted to hospital;
  • Treatable conditions, such as injuries from falls, were among the most common reasons for treatment in hospital; and
  • The hospitalization rate of long-term care residents with a DNH directive (7%) was about half of those without one (14%).

In other situations, the transfer may not have followed the patient’s documented wishes. Research suggests that the decision to transfer a long-term care resident to hospital is often made by family members.

Overall, the study found that hospital transfers for long-term care residents declined by about half over the study period. This coincides with a push to improve the quality of care in long-term care facilities. Results from this study suggest that hospitalizations of residents with a DNH directive could be further reduced by

  • Providing more palliative care services in long-term care settings to avoid the need for transfers; and
  • Focusing on prevention — nearly half of hospitalizations (46%) were from preventable causes, such as infections (e.g., pneumonia, urinary tract infections) and injuries from falls.

CIHI’s study was based on the annual assessments of almost 200,000 long-term care residents done between 2009–2010 and 2011–2012, making it the largest sample to date for a study on the topic in Canada.


“There is an ongoing national discussion about end-of-life care. Advance directives help individuals to communicate their preferences for interventions and treatments when they are no longer able to make decisions for themselves. While these conversations are sometimes difficult, it’s important for families to discuss with their loved ones what kind of care they want or don’t want at the end of their lives.”

— Kathleen Morris, Vice President, Research and Analysis, CIHI