The Role of Advanced Practice Registered Nurses in the Completion of Physician Orders for Life-Sustaining Treatment.

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms.
OBJECTIVE: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms.
DESIGN: Cross-sectional. SETTING/
SUBJECTS: 226,101 Oregon POLST Registry forms from 2010 to 2015. MEASUREMENTS: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA).
RESULTS: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign.
CONCLUSIONS: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.

Introduction

Individuals facing advanced illnesses have differing goals for care, and they often reach out to healthcare professionals for help in matching their goals with available medical interventions.[1,2] The Physician Orders for Life-Sustaining Treatment (POLST) paradigm has emerged as a powerful tool to guide conversations about end-of-life treatments with patients and to preserve patient preferences as medical orders.[3-30] As of May of 2016, 47 states are either developing or have already endorsed POLST programs. Each state differs slightly in the structure and policies that characterize their POLST programs. Of note, variation exists between states with respect to the type of healthcare professionals who are permitted to sign and execute POLST forms. States differ in the terminology used to describe their programs. However, most endorsed states use either “physician orders” or “medical orders” in the name of their program, which may not be considered inclusive of all signing healthcare professionals.[31]

Although states retain autonomy in determining the details of their programs, the National POLST Paradigm Task Force (NPPTF) recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms.[31] Some states have become more inclusive as their programs mature. For example, CA and WV passed legislation in 2016 allowing APRNs to execute POLST orders. However, of the 19 states with programs endorsed by the NPPTF in 2016, 3 allow only physicians to sign POLST orders.[31] These three states (NY, LA, and GA) and the growing number of developing state programs will face the decision as to whether or when they will permit APRNs to sign POLST forms in the future.

For patients facing an advanced illness, timely access to end-of-life care and counseling can have significant bearing on their quality of life and place of death.[27,28,30,32] Remembering that POLST orders are completed a median of six weeks before death, restricting the work force available to assist in form completion may add to delays and unwanted treatments.[27] APRNs are recommended as a means to increase access to patient-centered services and care.[29,33-36] This recommendation is supported by new Centers for Medicare and Medicaid Services (CMS) billing codes to be used by both physicians and APRNs as of January of 2016 for goals of care counseling reimbursement.[37] This brief report uses data from the Oregon POLST Registry to explore the role that APRNs can play, as part of the patient's interdisciplinary care team, in this important element of end-of-life care.

Materials and Methods

Study setting

The study included data from the Oregon POLST Registry, a state-wide electronic registry of Oregon POLST forms. These data were collected under quality assurance and quality improvement for the Oregon POLST Registry and were not submitted for IRB review. No patient data were accessed, thereby protecting all patient confidentiality. Upon voluntary completion of a POLST form, the signing healthcare professional or his or her designee is mandated to submit the form to the Registry unless a patient specifically opts out. POLST forms in the Registry from 2010 to 2015 were analyzed for the authorizing healthcare professional discipline. The primary aim was to assess the percentage of forms that were signed by APRNs each year as compared with either physicians or PAs.

Population

The study included 226,101 Oregon POLST Registry forms that were entered from 2010 to 2015.

Variables

The variable analyzed from the Oregon POLST Registry was the type of healthcare professional who signed each POLST form as well as the percentage completed by each professional discipline during each year of the study.

Data analysis

The data were analyzed using descriptive statistics to determine the number and percentages of completed POLST forms by the professional signing the forms.

Results

From 2010 to 2015, 226,101 forms were added to the Oregon POLST Registry. Of those, 10.9%, or 24,620, forms were signed by APRNs, and 85.3% were signed by physicians (the remaining 3.8% were signed by PAs). Figure 1 shows the percentage of POLST forms signed by APRNs for each year from 2010 to 2015. The percentage of POLST forms signed by APRNs in Oregon increased from 9.0% to 11.4% between 2010 and 2012 of registry operation and has remained relatively flat during the remaining four years.

Proportion of registered physician orders for life-sustaining treatment forms signed by advanced practice registered nurses from 2010 to 2015.

Table 1 depicts states with endorsed POLST programs that allow APRNs and physicians to sign POLST forms, or only allow physicians to sign POLST forms. Out of the 19 states with endorsed programs, 3 (NY, LA, and GA) do not allow APRNs to sign POLST forms.

1.

Health Professional Disciplines Authorized to Sign Physician Orders for Life-Sustaining Treatment Forms

APRNs signing before 2016	APRNs signing authorized in 2016	Physician signing only
Colorado	California	Georgia
Hawaii	West Virginia	Louisiana
Idaho		New York
Iowa
Maine
Montana
North Carolina
Oregon
Pennsylvania
Tennessee
Utah
Virginia
Washington
Wisconsin

Only established POLST Programs endorsed before August 2016 are included in this analysis. All states that allowed APRNs to sign POLST forms also allow physicians and physician assistants to sign. Developing programs are not included.

APRNs, advanced practice registered nurse; POLST, physician orders for life-sustaining treatment.

Discussion

End-of-life and palliative care are interdisciplinary endeavors. Patient-centered treatment often requires the expertise of primary and specialist care. A palliative care clinician provides such specialist care. Goals of care conversations need to take place and should be initiated by the healthcare professional who knows the patient best.[38] A relationship with continuity is the ideal context for discussing goals of care that may lead to POLST completion in seriously ill patients. APRNs may have that relationship with a patient more than other clinicians. There is general agreement, though, that the number of physicians and APRNs trained in hospice and palliative medicine is grossly inadequate to meet the needs of the growing population of aging Americans.[39,40]

Primary care and palliative care are increasingly team based and interdisciplinary. APRNs work both collaboratively with and independent of physicians in many settings and play an integral role in the care of patients with advanced illness.[28,29,33-36] Our data suggest that in Oregon, a state that has permitted APRNs to sign POLST forms since 2001, the percentage of POLST forms signed by APRNs is slowly increasing. These results suggest that APRNs are well positioned to initiate goals of care conversations because they know the patients best, are invited to take the lead by the healthcare team, or they have advanced training in palliative care or geriatrics. As APRNs become a significant and recognized part of the interdisciplinary cancer care team, APRNs are positioned to take on a greater role in advance care planning. Research has shown that APRNs have positive attitudes but moderate knowledge and limited experience in advance care planning.[41,42] States that allow APRNs and physicians to sign POLST forms honor the role of both professional groups in preserving patient preferences.

Access is not consistent across all endorsed states. State licensure and practice laws are a barrier to APRNs' practicing to the fullest extent of their education and training, specifically with regard to POLST forms.[43,44] Communication with POLST program leaders from states that do not allow APRNs to sign revealed that lack of support from state medical associations represents a major roadblock in approving more inclusive POLST policies. In contrast, California recently passed legislation in 2016 allowing APRNs to sign POLST forms, with support from the California Medical Association (CMA). The CMA recognized that authorizing APRNs to sign POLST forms facilitated completion because timely access to a physician can sometimes be difficult to obtain.[45]

Allowing APRNs, as part of the team of interprofessional healthcare professionals, to sign POLST forms is an important step in providing timely, patient-centered care. At its core, the POLST paradigm exists to facilitate and honor goals of care conversations between patients and the healthcare professionals who know them best. For some patients, that professional might be a physician, for others it might be an APRN. It is important, not only from a political and economic perspective but also from a humanistic perspective, that POLST policies recognize and honor the range of professionals who are best positioned to counsel patients and document their wishes.

Limitations

This was a retrospective analysis of available data and was not intended to quantify the relationship between the proportion of POLST forms signed by APRNs and the quality of end-of-life care. This was not a random sample, as individuals who choose to have a POLST form may be different from the general population.

Conclusions

Eleven percent of POLST forms in the Oregon Registry are signed by APRNs. There are an increasing number of states with endorsed POLST programs that are allowing APRNs to sign POLST forms. This trend suggests that APRNs are performing a vital and growing role in advance care planning including POLST completion.