Life‐Sustaining Treatment Decisions for Nursing Home Residents: Who Discusses, Who Decides and What Is Decided?

Levin, Jennifer R.; Wenger, Neil S.; Ouslander, Joseph G.; Zellman, Gail L.; Schnelle, John F.; Buchanan, Joan L.; Hirsch, Susan H.; Reuben, David B.

doi:10.1111/j.1532-5415.1999.tb01905.x

Cited by 75 publications

(55 citation statements)

References 26 publications

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“…This finding is consistent with other research, 6 including studies suggesting that patients' recall of informed consent discussions is most accurate immediately after the conversation occurs and degrades rapidly thereafter. 19 The phrasing of the interview questions may have contributed to this finding, because the questions posed were focused on general treatment decisions rather than specific treatments or goals of care, and no further information was collected to clarify apparent inconsistencies or explore the reason for changes.…”

Section: Discussionsupporting

confidence: 91%

“…1,3,4 Family and resident treatment preferences are an important variable in decisions about whether or not to provide treatments including hospitalization. [5][6] The Physician Orders for Life-Sustaining Treatment (POLST) program is designed to document patient treatment preferences for resuscitation, medical interventions, antibiotics, and artificial nutrition as medical orders that transfer with patients throughout the health care setting. 7 POLST was originally developed in Oregon and is now used in more than 20 states.…”

Section: Introductionmentioning

confidence: 99%

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Use of the Physician Orders for Life-Sustaining Treatment Program for Patients Being Discharged from the Hospital to the Nursing Facility

Hickman

Nelson

Smith-Howell

et al. 2014

Journal of Palliative Medicine

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Background: The Physician Orders for Life-Sustaining Treatment (POLST) documents patient preferences as medical orders that transfer across settings with patients. Objectives: The objectives were to pilot test methods and gather preliminary data about POLST including (1) use at time of hospital discharge, (2) transfers across settings, and (3) consistency with prior decisions. Study Design: Descriptive with chart abstraction and interviews. Participants: Participants were hospitalized patients discharged to a nursing facility and/or their surrogates in La Crosse County, Wisconsin. Measurements: POLST forms were abstracted from hospital records for 151 patients. Hospital and nursing facility chart data were abstracted and interviews were conducted with an additional 39 patients/surrogates. Results: Overall, 176 patients had valid POLST forms at the time of discharge from the hospital, and many (38.6%; 68/176) only documented code status. When the whole POLST was completed, orders were more often marked as based on a discussion with the patient and/or surrogate than when the form was used just for code status (95.1% versus 13.8%, p < .001). In the follow-up and interview sample, a majority (90.6%; 29/32) of POLST forms written in the hospital were unchanged up to three weeks after nursing facility admission. Most (71.9%; 23/32) appeared consistent with patient or surrogate recall of prior treatment decisions. Conclusion: POLST forms generated in the hospital do transfer with patients across settings, but are often used only to document code status. POLST orders appeared largely consistent with prior treatment decisions. Further research is needed to assess the quality of POLST decisions.

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Section: Discussionsupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

Use of the Physician Orders for Life-Sustaining Treatment Program for Patients Being Discharged from the Hospital to the Nursing Facility

Hickman

Nelson

Smith-Howell

et al. 2014

Journal of Palliative Medicine

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“…While this analysis did not explore the orders contained within the POLST, most POLST forms from nursing home residents contain orders to avoid resuscitation. 18,19 Surveys of older people 20 and nursing home residents 21 consistently show that people with greater functional disability tend to desire less aggressive care, and studies of older people looking ahead to future compromised health states demonstrate elicited preferences focusing on comfortoriented care and non-aggressive treatments. 22,23 Possible explanations for fewer POLSTs among compromised residents include the unavailability of proxy decision-makers, family members' uncertainty about loved ones' wishes, or perhaps that long-stay severely compromised nursing home residents previously indicated a preference to live in this health state.…”

Section: Discussionmentioning

confidence: 99%

“…Variable uptake of end-of-life interventions has been previously demonstrated and is an aspect of long-term care in need of improvement. 20 These data suggest areas for possible quality improvement, such as facilities that are slow adopters of POLST and unsigned forms. An unsigned POLST in the patient record may reflect a POLST form that is in process, especially for residents whose length of stay in the nursing home is very short and thus may be discharged prior to fully completing the form; however, because an unsigned POLST is not legally valid, it should not be stored in the patient record.…”

Section: Discussionmentioning

confidence: 99%

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents

Jennings

Zingmond²,

Louie³

et al. 2016

J GEN INTERN MED

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BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) is a tool that facilitates the elicitation and continuity of life-sustaining care preferences. POLST was implemented in California in 2009, but how well it disseminated across a large, racially diverse population is not known and has implications for end-of-life care. OBJECTIVE: To evaluate the use of POLST among California nursing home residents, including variation by resident characteristics and by nursing home facility. DESIGN: Observational study using California Minimum Data Set Section S. PARTICIPANTS: A total of 296,276 people with a stay in 1,220 California nursing homes in 2011. MAIN MEASURES:The proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; change in POLST use during 2011; and POLST completion and unsigned forms within nursing homes. KEY RESULTS: During 2011, POLST completion increased from 33 to 49 % of California nursing home residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status. There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. Variation in POLST completion among nursing homes far exceeded that attributable to resident characteristics with 40 % of facilities having ≥80 % of long-stay residents with a completed POLST, while 20 % of facilities had ≤10 % of long-stay residents with a completed POLST. Thirteen percent of nursing home residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid. CONCLUSIONS: Statewide nursing home data show broad uptake of POLST in California without racial disparity. However, variation in POLST completion among nursing homes identifies potential areas for quality improvement.KEY WORDS: end-of-life care; nursing home; long-term care; quality improvement. J Gen Intern Med 31(10):1119-26 DOI: 10.1007/s11606-016-3728-9 © Society of General Internal Medicine 2016 INTRODUCTIONPhysician Orders for Life-Sustaining Treatment (POLST) facilitates elicitation of life-sustaining treatment preferences from patients and is designed to improve the transition of these preferences, in the form of physician orders, across care settings. POLST captures preferences concerning cardiopulmonary resuscitation, overall aggressiveness of care, hospital transfer, and artificial nutrition. 1 The document is particularly useful for residents of nursing facilities because many residents live in compromised health states and would not desire burdensome treatments 2 and also because it is common for nursing home residents to transition to the emergency room and the hospital 3 wh...

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“…Recent data indicate that approximately 32% of nursing home residents have identified a health care proxy and 74% have a DNR order. 2 Unfortunately, while both these measures are better than no advance planning, they fail to address the majority of issues facing nursing home residents. Orders to forgo artificial nutrition and hydration and orders to forgo hospitalization are written in fewer than 8% of nursing homes, according to a 10-state survey, and these rates have remained unchanged since implementation of the Patient Self-Determination Act.…”

Section: The Current Status Of Advance Medical Planning In Nursing Homesmentioning

confidence: 99%

Adapting Advance Medical Planning for the Nursing Home

Gillick

2004

Journal of Palliative Medicine

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Life‐Sustaining Treatment Decisions for Nursing Home Residents: Who Discusses, Who Decides and What Is Decided?

Abstract: Chart orders to limit therapy are common, but physician-resident discussions about life-sustaining treatments are not. Far more family members than residents report such discussions with the resident's physicians.

Cited by 75 publications

References 26 publications

Use of the Physician Orders for Life-Sustaining Treatment Program for Patients Being Discharged from the Hospital to the Nursing Facility

Use of the Physician Orders for Life-Sustaining Treatment Program for Patients Being Discharged from the Hospital to the Nursing Facility

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents

Adapting Advance Medical Planning for the Nursing Home

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