more likely to offer one or both of these advance directives than
a nursing home that is not innovative.
Also, nursing homes that are both nonprofit and not
members of a multifacility chain will be more likely to use one
or both of these directives than would any other category of
Data for this project come from the 2004 National Nursing
Home Survey (NNHS). This dataset is used as it remains the
only nationally available sample documenting the presence
of the POLST Program and Five Wishes in the nursing home
setting. The NNHS is a publicly available series of nationally
representative surveys of nursing homes across the nation and
includes information on the services, staff, and residents of
After removing observations with missing data, the
final sample for this study consisted of 949 nursing homes
(weighted sample = 13,261). The data were analyzed using
Two separate models are presented. The first model
explored the likelihood of the nursing home using Five Wishes,
and the second model examined the use of the POLST program.
The sample characteristics reveal that approximately 16
percent of nursing homes participated in the POLST program
and/or Five Wishes. The findings of the three logistic models
support the hypothesis that the use of an advance directive
innovation may be associated with other appropriate staffing
and clinical innovations.
Offering gardening, pets or pet therapy, inter-generational
activities and also having in-house hospice services were
associated with an increased likelihood that the nursing home
would offer the POLST program. The presence of Five Wishes
was associated only with having an in-house hospice program.
The second hypothesis suggested that nursing homes that
are both independent and nonprofit would be more likely to
offer these advance directives than would other categories of
nursing home. The findings of the logistic regression models
reveal that for the Five Wishes model, nursing homes that are
both nonprofit and members of a multi-facility chain were more
likely to offer this advance directive than were other categories
of nursing homes.
For the POLST program model, nursing homes that were
for-profit and not members of a multi-facility chain were
more likely than other types of nursing homes to offer these
What are the implications of your findings?
The commitment to nursing home innovations needs to be
evidenced across multiple organizational levels. This includes
both the clinical and top management levels and the structural
and process levels. Without resource commitment and
investment, innovations may be less effective.
Furthermore, while the concept of a “good death” may vary
between the resident and the institution, representatives of
both groups may agree that one component of this is having
final wishes honored. Implementing appropriate instruments
to communicate these wishes is one step toward achieving a
What are the next steps to further your work in this area?
This study used quantitative data analysis to explore national
trends, yet, little is known about how nursing homes practically
communicate residents’ wishes to relevant service providers.
Some facilities place copies of the directives in resident
medical records. Providers must first access those records.
Dr. Jullet A. Davis, MHA
Associate Professor of Health Care Management