Choosing Wisely:

Don’t recommend aggressive or hospital-level care for a frail elder without a clear understanding of the individual’s goals of care and the possible benefits and burdens.

Rationale and Comments: Hospital-level care has known risks, including delirium, infections, side effects of medications and treatments, disturbance of sleep, and loss of mobility and function. These risks are often more significant for patients in the post-acute and long-term care setting, who are more likely to be frail and to have multimorbidity, functional limitations, and dementia. Therefore, for some frail elders, the balance of benefits and harms of hospital-level care may be unfavorable. To avoid unnecessary hospitalizations, care providers should engage in advance care planning by defining goals of care for the patient and discussing the risks and benefits of various interventions, including hospitalization, in the context of prognosis, preferences, indications, and the balance of risks and benefits. Advance directives such as the Physician Orders for Life Sustaining Treatment paradigm form and Do Not Hospitalize orders communicate a patient’s preferences about end-of-life care. Patients with Do Not Hospitalize orders are less likely to be hospitalized than those who do not have these directives. Patients who opt for less-aggressive treatment options are less likely to be subjected to unnecessary, unpleasant, and invasive interventions and the risks of hospitalization.
Sponsoring Organizations:
  • Society for Post-Acute and Long-Term Care Medicine
  • Sources:
  • Expert consensus
  • Disciplines:
  • Geriatric Medicine
  • References: • Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993 Feb 1;118(3):219.
    • Deciding About Going to the Hospital. Interact v4.0 Tool. Florida Atlantic University; 2011 [cited 2015 Jan 2]. Available from: http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20V%204%20Deciding_About_Going_to_Hosptial%20Nov%2017%202014.pdf.
    • Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014 Mar 8;383(9920):911-22.
    • Murray LM, Laditka SB. Care transitions in older adults from nursing homes to hospitals: implications for long-term care practice, geriatrics education, and research. J Am Med Dir Assoc. 2010 May;11(4):231-8.
    • Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005 Jul 20;294(3):359-65.

    Email Alerts

    Don't miss a single issue. Sign up for the free AFP email table of contents.

    Sign Up Now