A doctor speaking with a nursing home resident

More clinicians now use Physician Orders for Life-Sustaining Treatment forms to record care wishes for nursing facility residents, but whether the resulting conversations lead to high-quality care remains unclear. 

That’s according to geriatricians from the University of California, San Francisco. In an editorial released Wednesday in the Journal of the American Geriatrics Society, Kenneth Lam M.D., MAS, and colleagues said that while documenting residents’ care preferences is important, the value of these efforts may vary for some residents or resident groups.

POLST is a portable medical order and a relatively new form of advance directive for patients with serious or life-limiting illnesses. In 2011, California was the first state to require nursing homes to record completion of POLST in the Minimum Data Set, and the orders are widely used elsewhere.

The rise of POLST use is a good thing at face value, the authors noted. But recent nursing home research has yet to show that these forms can substitute for “meaningful discussions about values, life goals and preferences” as actual medical decisions arise, they said.

For short-stay residents, for example, “good care may be related more to quality conversations and frequently updated decision-making about going home, not quality conversations about a transfer to hospital or CPR that may never happen during their stay,” the authors wrote.

“Discussions of avoiding transfer to hospital, end-of-life, and DNR at the start of a short-stay admission can therefore be jarring and incongruent with a patient’s recent experience and expectations,” they explained.

In contrast, long-stay residents may be more at risk for life-threatening events due to medical conditions or advanced frailty. They are also likely to have longer-term relationships with their clinicians. POLST discussions may therefore be more valuable additions to their care, the editorial suggested.

More inquiry into this relatively new advanced directives choice is needed to ensure that it contributes to high-quality care, Lam and colleagues concluded.

Related articles:

Q&A: Clinical best practices when gauging residents’ end-of-life preferences — a POLST expert weighs in

POLST form triples odds that residents’ treatment wishes are known: study

Six years after mandate, most of state’s nursing home residents had POLST forms