Susan E Hickman1,2,3,4, Alexia M Torke2,3,4, Nicholette Heim Smith1, Anne L Myers1, Rebecca L Sudore5, Bernard J Hammes6, Greg A Sachs2,3,4. 1. Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA. 2. Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA. 3. Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA. 4. Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA. 5. Division of Geriatrics, School of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA. 6. Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin, USA.
Abstract
BACKGROUND: The reasons for discordance between advance care planning (ACP) documentation and current preferences are not well understood. The POLST form offers a unique opportunity to learn about the reasons for discordance and concordance that has relevance for POLST as well as ACP generally. DESIGN: Qualitative descriptive including constant comparative analysis within and across cases. SETTING: Twenty-six nursing facilities in Indiana. PARTICIPANTS: Residents (n = 36) and surrogate decision-makers of residents without decisional capacity (n = 37). MEASUREMENTS: A semi-structured interview guide was used to explore the reasons for discordance or concordance between current preferences and existing POLST forms. FINDINGS: Reasons for discordance include: (1) problematic nursing facility practices related to POLST completion; (2) missing key information about POLST treatment decisions; (3) deferring to others; and (4) changes over time. Some participants were unable to explain the discordance due to a lack of insight or inability to remember details of the original POLST conversation. Explanations for concordance include: (1) no change in the resident's medical condition and/or the resident is unlikely to improve; (2) use of the substituted judgment standard for surrogate decision-making; and (3) fixed opinion about what is "right" with little to no insight. CONCLUSION: Participant explanations for discordance between existing POLST orders and current preferences highlight the importance of adequate structures and processes to support high quality ACP in nursing facilities. Residents with stable or poor health may be more appropriate candidates for POLST than residents with a less clear prognosis, though preferences should be revisited periodically as well as when there is a change in condition to help ensure existing documentation is concordant with current treatment preferences.
BACKGROUND: The reasons for discordance between advance care planning (ACP) documentation and current preferences are not well understood. The POLST form offers a unique opportunity to learn about the reasons for discordance and concordance that has relevance for POLST as well as ACP generally. DESIGN: Qualitative descriptive including constant comparative analysis within and across cases. SETTING: Twenty-six nursing facilities in Indiana. PARTICIPANTS: Residents (n = 36) and surrogate decision-makers of residents without decisional capacity (n = 37). MEASUREMENTS: A semi-structured interview guide was used to explore the reasons for discordance or concordance between current preferences and existing POLST forms. FINDINGS: Reasons for discordance include: (1) problematic nursing facility practices related to POLST completion; (2) missing key information about POLST treatment decisions; (3) deferring to others; and (4) changes over time. Some participants were unable to explain the discordance due to a lack of insight or inability to remember details of the original POLST conversation. Explanations for concordance include: (1) no change in the resident's medical condition and/or the resident is unlikely to improve; (2) use of the substituted judgment standard for surrogate decision-making; and (3) fixed opinion about what is "right" with little to no insight. CONCLUSION: Participant explanations for discordance between existing POLST orders and current preferences highlight the importance of adequate structures and processes to support high quality ACP in nursing facilities. Residents with stable or poor health may be more appropriate candidates for POLST than residents with a less clear prognosis, though preferences should be revisited periodically as well as when there is a change in condition to help ensure existing documentation is concordant with current treatment preferences.
Authors: Catherine L Auriemma; Christina A Nguyen; Rachel Bronheim; Saida Kent; Shrivatsa Nadiger; Dustin Pardo; Scott D Halpern Journal: JAMA Intern Med Date: 2014-07 Impact factor: 21.873
Authors: Rebecca L Sudore; C Seth Landefeld; Brie A Williams; Deborah E Barnes; Karla Lindquist; Dean Schillinger Journal: J Gen Intern Med Date: 2006-08 Impact factor: 5.128
Authors: Daren K Heyland; Doris Barwich; Deb Pichora; Peter Dodek; Francois Lamontagne; John J You; Carolyn Tayler; Pat Porterfield; Tasnim Sinuff; Jessica Simon Journal: JAMA Intern Med Date: 2013-05-13 Impact factor: 21.873
Authors: Simon M Cohen; Angelo E Volandes; Michele L Shaffer; Laura C Hanson; Daniel Habtemariam; Susan L Mitchell Journal: J Pain Symptom Manage Date: 2018-09-29 Impact factor: 3.612
Authors: Kelly C Vranas; Wesley Plinke; Donald Bourne; Devan Kansagara; Robert Y Lee; Erin K Kross; Christopher G Slatore; Donald R Sullivan Journal: J Am Geriatr Soc Date: 2021-09-22 Impact factor: 7.538
Authors: Lee A Jennings; Neil S Wenger; Li-Jung Liang; Punam Parikh; David Powell; Jose J Escarce; David Zingmond Journal: J Am Geriatr Soc Date: 2022-03-11 Impact factor: 7.538
Authors: Anastasia A Mallidou; Coby Tschanz; Elisabeth Antifeau; Kyoung Young Lee; Jenipher Kayuni Mtambo; Holly Heckl Journal: BMC Health Serv Res Date: 2022-09-22 Impact factor: 2.908