Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting

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Objectives: Determine the use and utility of the Physician Orders for Life-Sustaining Treatment (POLST) program in a community where powers of attorney for health care (POAHCs) are prevalent. Methods: A retrospective review of medical record and death certificate data of 400 adults who died between September 1, 2007, and March 31, 2008, in the La Crosse County, Wisconsin community. Demographic and cause-of-death data were collected from death certificates. Information about POAHC, POLST forms, and medical treatments provided in the last 30 days of life were abstracted from decedents' medical records. Results: Sixty-seven percent of decedents had a POLST form, whereas 22% had POAHC alone. In comparison with decedents with POAHC alone, decedents with a POLST form were significantly older (83 versus 77 years, p < 0.001), more likely to die in a nursing home than in a hospital ( p < 0.001), and more likely to die from a terminal or chronic illnesses (97%). Decedents with POLST orders for higher levels of medical treatment received more treatment, and in only two cases was there evidence that treatment was discrepant with POLST orders. In 31% of all POLST forms, the person appointed in the POAHC consented to the POLST orders. Conclusions: POLST can be a highly effective program to ensure that patient preferences are known and honored in all settings. POAHCs are valuable because they identify appropriate surrogates when patients are incapacitated.

Section: Discussionmentioning

confidence: 89%

mentioning

confidence: 99%

The POLST Program: A Retrospective Review of the Demographics of Use and Outcomes in One Community Where Advance Directives Are Prevalent

Hammes

Rooney

Gundrum

et al. 2012

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“…8 POLST offers advantages over traditional code status orders by permitting documentation of a wide range of treatment preferences including resuscitation, medical interventions such as hospitalization, antibiotics, and artificial nutrition. [9][10][11][12][13] It is recommended that the POLST be generated before hospital discharge for eligible patients 14 to help ensure that patients have orders available during transport and upon arrival at the facility or home. When patients lack decisional capacity and there are no orders available reflecting prior treatment decisions, the default is to provide all available medical treatment.…”

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

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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.

“…37 Tracking this innovation as a natural experiment, investigators have found evidence that POLST is effective to facilitate care consistent with preferences for older patients in nursing homes, PACE, and hospice. [38][39][40] Can Interventions Improve the Quality of Decision Making?…”

Section: -31mentioning

confidence: 99%

Research Priorities for Geriatric Palliative Care: Goals, Values, and Preferences

Hanson¹,

Winzelberg²

2013

Older patients and their families desire control over health decisions in serious illness. Experts recommend discussion of prognosis and goals of care prior to decisions about treatment. Having achieved longevity, older persons often prioritize other goals such as function, comfort, or family support-and skilled communication is critical to shift treatment to match these goals. Shared decision making is the ideal approach in serious illness. Older patients desire greater family involvement; higher rates of cognitive impairment mean greater dependency on surrogates to make decisions. Despite the importance of communication, fewer than half of older patients or families recall treatment discussions with clinicians, and poor quality communication adversely affects family satisfaction and patient outcomes. Direct audiorecording of clinical encounters and longitudinal studies of communication and treatment decisions have yielded important insights into the quality of clinical communication. Current clinical practice rarely meets standards for shared decision making. Innovative methods to record and use patient preferences show promise to overcome the limitations of traditional advance directives. Decision aids, intensive clinician training, and structured interpersonal communication interventions have all been shown to be effective to improve the quality of communication and decision making. Priorities for geriatric palliative care research, building on these insights, now include empirical testing of communication approaches for surrogates and for diverse populations, exploration of meaningful ways to communicate prognosis, and expansion of intervention research.What Defines Quality in Health Care Communication?