A nursing home resident sits with a visitor

Most California nursing home residents had completed physician orders for life-sustaining treatment, or POLST, within six years after POLST reporting was mandated in the Minimum Data Set, according to a newly published follow-up study.

POLST forms allow people with life-limiting conditions, such as advanced frailty, to summarize treatment preferences as physician’s medical orders. After concerted efforts by community coalitions, POLST was legally recognized in California in 2009 across healthcare settings. The state, in 2010, also was the first to mandate that completion of the orders be documented in the nursing home MDS. 

Since that time, POLST completion has become the norm in these settings, investigators said. By 2016, most long-stay residents (81%) and 68% of short-stay residents had documented POLST, reported David Zingmond M.D., Ph.D., of the University of California, Los Angeles.

More use among functionally dependent

POLST completion was greater among residents who had more functional dependence, and lower among those who were more cognitively impaired. Greater functional and cognitive impairment were also associated with do-not-resuscitate (DNR) orders, Zingmond and colleagues wrote. Among those with a POLST in 2016, 54% of long-stay and 41% of short-stay residents had a DNR order. 

Notably, among residents with a completed DNR, more than 90% had orders for limited medical interventions or comfort measures. Less than 6% of these residents had POLST that contradicted these specifications, the researchers wrote.

The study also found disparities between groups and facilities. Racial and ethnic minorities indicated more aggressive care preferences, and a higher five-star facility quality rating from the Centers for Medicare & Medicaid Services was associated with greater POLST completion.

Growing interest in POLST

The call for standardizing POLST forms has grown steadily over the years. The long-term care industry endorsed a nationally recognized POLST form in 2020 and the National POLST organization is dedicated to promoting standardizing a form and education throughout the United States. National POLST recognized California’s POLST as a mature program April 25, 2016. Completion of the order by the individual is voluntary.

Nursing home residents who have a signed POLST form significantly increase the likelihood that their treatment preferences are known, according to researchers from the Indiana University Center for Aging Research, Regenstrief Institute, who study POLST implementation in the long-term care industry and advance care directives.

POLST forms may be more specific than those of advance directives and DNR orders. During emergency situations and when a patient is incapacitated, they can help care providers answer questions about issues such as intubation, hospitalization and comfort-based care.

National POLST has created a National POLST form, available at www.polst.org.