Context: Do-not-hospitalize (DNH) orders in assisted living facilities (ALFs) are often misunderstood, ignored, or countermanded by direct care workers (DCWs), potentially leading to residents being sent to the hospital against their wishes.

Objectives: The primary purpose of this study was to gather sufficient qualitative data to create an intervention that would help prevent DCWs from sending residents with DNH orders to the hospital against their wishes. To accomplish this goal, the study centered on three research objectives: 1) to understand more fully how DCWs interpret DNH orders; 2) to determine if carrying out DNH orders causes moral distress for DCWs; and 3) to ascertain what interventions, if any, DCWs think would help keep ALF residents with DNH orders in their facilities.

Methods: This was a qualitative study including a descriptive survey followed by semi-structured interviews. Interviews explored participants’ experiences with DNH orders, end-of-life care in ALFs, and their overall experiences as DCWs. There were 8 participants; data saturation was achieved after 8 interviews. Results: The DCW participants were unfamiliar with DNH orders or Medical Orders for Scope of Treatment (MOST) forms, which are a type of advanced directive that includes an option for DNH. The participants’ thinking on end-of-life care was binary- hospice or hospital- and protocol driven. However, supportive leaders were able to help DCWs problem-solve these complicated scenarios, and potentially keep a resident with a DNH order out of the hospital. Participants were not morally distressed by caring for residents nearing the end of their lives. Instead, most participants were proud of the work they did in providing end-of-life care and their role in providing this care gave them purpose and meaning.

Future Directions: A logical next research step would be to devise an intervention where DCWs have 24-hour access to a palliative care nurse who would come into the ALF and address acute issues for residents with DNH orders. The study also underscored how little research has been done thus far on ALFs, including a lack of research on the safety, regulatory environment, role of the nurse, and quality of care for residents in these facilities. There are many future directions one might take in further examining the world of ALFs as they become an increasingly popular option for aging adults.

Document Type

Scholarly Project

Degree Name

Doctor of Nursing Practice (DNP)

Level of Degree


First Committee Member

Dr. Amy Levi


palliative care, geriatrics, assisted living facilities, do-not-hospitalize, MOST forms