Susan E Hickman1,2,3,4, Alexia M Torke5,6,7, Greg A Sachs5,6,7, Rebecca L Sudore8, Qing Tang9,10, Giorgos Bakoyannis9,10, Nicholette Heim Smith11, Anne L Myers11, Bernard J Hammes12. 1. Indiana University School of Nursing, Department of Community & Health Systems, 1101 West 10th Street, IN, 46202, Indianapolis, USA. hickman@iu.edu. 2. Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA. hickman@iu.edu. 3. Indiana University School of Medicine, Division of General Internal Medicine & Geriatrics, 1101 West 10th Street, IN, 46202, Indianapolis, USA. hickman@iu.edu. 4. Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA. hickman@iu.edu. 5. Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA. 6. Indiana University School of Medicine, Division of General Internal Medicine & Geriatrics, 1101 West 10th Street, IN, 46202, Indianapolis, USA. 7. Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA. 8. Division of Geriatrics, University of California San Francisco, School of Medicine, San Francisco, CA, USA. 9. Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA. 10. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA. 11. Indiana University School of Nursing, Department of Community & Health Systems, 1101 West 10th Street, IN, 46202, Indianapolis, USA. 12. Respecting Choices, A Division of C-TAC Innovations, La Crosse, WI, USA.
Abstract
BACKGROUND: It is essential to high-quality medical care that life-sustaining treatment orders match the current, values-based preferences of patients or their surrogate decision-makers. It is unknown whether concordance between orders and current preferences is higher when a POLST form is used compared to standard documentation practices. OBJECTIVE: To assess concordance between existing orders and current preferences for nursing facility residents with and without POLST forms. DESIGN: Chart review and interviews. SETTING: Forty Indiana nursing facilities (29 where POLST is used and 11 where POLST is not in use). PARTICIPANTS: One hundred sixty-one residents able to provide consent and 197 surrogate decision-makers of incapacitated residents with and without POLST forms. MAIN MEASUREMENTS: Concordance was measured by comparing life-sustaining treatment orders in the medical record (e.g., orders about resuscitation, intubation, and hospitalization) with current preferences. Concordance was analyzed using population-averaged binary logistic regression. Inverse probability weighting techniques were used to account for non-response. We hypothesized that concordance would be higher in residents with POLST (n = 275) in comparison to residents without POLST (n = 83). KEY RESULTS: Concordance was higher for residents with POLST than without POLST (59.3% versus 34.9%). In a model adjusted for resident, surrogate, and facility characteristics, the odds were 3.05 times higher that residents with POLST had orders for life-sustaining treatment match current preferences in comparison to residents without POLST (OR 3.05 95% CI 1.67-5.58, p < 0.001). No other variables were significantly associated with concordance. CONCLUSIONS: Nursing facility residents with POLST are significantly more likely than residents without POLST to have concordance between orders in their medical records and current preferences for life-sustaining treatments, increasing the likelihood that their treatment preferences will be known and honored. However, findings indicate further systems change and clinical training are needed to improve POLST concordance.
BACKGROUND: It is essential to high-quality medical care that life-sustaining treatment orders match the current, values-based preferences of patients or their surrogate decision-makers. It is unknown whether concordance between orders and current preferences is higher when a POLST form is used compared to standard documentation practices. OBJECTIVE: To assess concordance between existing orders and current preferences for nursing facility residents with and without POLST forms. DESIGN: Chart review and interviews. SETTING: Forty Indiana nursing facilities (29 where POLST is used and 11 where POLST is not in use). PARTICIPANTS: One hundred sixty-one residents able to provide consent and 197 surrogate decision-makers of incapacitated residents with and without POLST forms. MAIN MEASUREMENTS: Concordance was measured by comparing life-sustaining treatment orders in the medical record (e.g., orders about resuscitation, intubation, and hospitalization) with current preferences. Concordance was analyzed using population-averaged binary logistic regression. Inverse probability weighting techniques were used to account for non-response. We hypothesized that concordance would be higher in residents with POLST (n = 275) in comparison to residents without POLST (n = 83). KEY RESULTS: Concordance was higher for residents with POLST than without POLST (59.3% versus 34.9%). In a model adjusted for resident, surrogate, and facility characteristics, the odds were 3.05 times higher that residents with POLST had orders for life-sustaining treatment match current preferences in comparison to residents without POLST (OR 3.05 95% CI 1.67-5.58, p < 0.001). No other variables were significantly associated with concordance. CONCLUSIONS: Nursing facility residents with POLST are significantly more likely than residents without POLST to have concordance between orders in their medical records and current preferences for life-sustaining treatments, increasing the likelihood that their treatment preferences will be known and honored. However, findings indicate further systems change and clinical training are needed to improve POLST concordance.
Entities:
Keywords:
advance care planning; nursing home; palliative care
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