A clear need exists to improve the quality of Physician’s Orders for Life-Sustaining Treatment, or POLST, in nursing home facilities, says Susan E. Hickman, Ph.D. An expert on the subject, she spoke with the McKnight’s Clinical Daily about her team’s latest findings on clinical best practices in advance care planning.
Hickman is director of the IU Center for Aging Research at Regenstrief Institute, a professor in the Indiana University Schools of Nursing and Medicine, and a senior affiliate faculty member in the IU Health Fairbanks Center for Medical Ethics.
In one of her new studies, conducted in 29 nursing homes, less than half of all POLST forms were concordant with residents’ current preferences, and more than five times as likely to be concordant when orders reflected preferences for comfort-focused care.
But in a complimentary study, the investigators were surprised to find that some residents were uninterested in fixing any discrepancies. This finding highlights the importance of ensuring that POLST use is voluntary. If 100% of residents have a POLST, then it is likely not being used appropriately, Hickman told McKnight’s.
Q: What prompted your team to take on your latest POLST nursing home studies?
A: The goal of POLST is to ensure patient preferences are known and honored. We previously found that POLST orders are associated with the treatments people receive; it does make a difference in outcomes. This is great news — if the orders actually reflect current preferences. POLST is intended to be completed based on a conversation about goals, values and preferences in light of the resident’s current medical condition and potential complications. However, my experiences doing education and outreach have left me concerned that this is not always happening.
Q: What is the estimated prevalence of POLST use in the long-term care industry?
A: Models based on POLST are present in almost every state. There is no way to directly measure prevalence, but I estimate that there are hundreds of thousands of long-term care residents with POLST forms across the country. This is because there are so many POLST-appropriate people in this setting, as POLST is intended for people with life-limiting illness at risk for life-threatening clinical events.
Q: What structures and processes are in place to assist long-term care facilities in managing POLST as part of advance care planning?
A: Structures include incorporating POLST and the outcomes of advance care planning conversations into the electronic medical record, training programs, education in new staff orientation, and dedicated time for these conversations by a trained, qualified staff member in collaboration with medical providers. There needs to be both support and accountability for these staff. Processes should include workflows, policies and meaningful review of preferences regularly and when there is a change of condition. Finally, the whole system needs to be set up for this to succeed, including policies and on-going education.
Q: What are the key takeaways from your latest studies for long-term care clinicians?
A: There are a couple of takeaways I would like to highlight. First, we found that both changes in resident health and a lack of information contributed to preference discordance. These findings suggest that POLST should be filled out by a trained staff member in collaboration with the treating provider and revisited regularly and whenever a person has a change in their health status. This is especially important for residents who express preferences to focus on maintaining health or prolonging life as opposed to comfort, as these preferences are more likely to change over time.
Second, our findings suggest focusing use on residents with preferences for comfort, as these preferences tend to be more stable. Interestingly, POLST was initially developed with these residents in mind.
Finally, our findings highlight the importance of supporting residents in medical decision-making and involving family whenever possible. We carefully screened residents and confirmed these residents make their own medical decisions, but our findings suggest some struggled with the more complex decisions on POLST.
Q: What might these results mean for other aspects of POLST, such as medication preferences. Are these better addressed through other means?
A: POLST orders provide guidance about a range of life-sustaining treatments including medications — it really reflects the current plan of care and goals to focus on comfort, selective interventions to maintain function, or full treatment to prolong life. POLST and the overall goal of care serves as the starting point for discussions about specific decisions.
Q: Where do we start when attempting to improve the quality of POLST discussions in nursing homes?
A: The first step is to identify a staff member who will assume responsibility and make this a clear part of their role with dedicated time. This cannot be an add-on task for a nurse or social services director who is already overloaded. Second, we need to make use of training resources to ensure this person is educated about advance care planning and POLST. The National POLST website has many free resources available at www.polst.org as a starting point. Third, we need to have strong processes in place for storage and regular review of preferences.
Q: Is there something you didn’t expect or were surprised to find?
A: About half of the participants with a mismatch between preferences and discordance did not accept our offer to notify staff so the POLST could be updated. Some wanted to talk with family, which suggests other values influence decision-making, but others just did not care enough to take any action. It was pretty surprising to realize that for some people, advance care planning is just not that important. This highlights the importance of ensuring that POLST use is voluntary and reinforces the National POLST quality indicator that if 100% of residents have a POLST, it is not being used appropriately.
Q: What is your ideal scenario for overall POLST implementation in the U.S. (a nationwide process? Interstate validity?)
A: National POLST has created a National POLST form with the goal of one, standardized tool. It is available at www.polst.org. I think this is a laudable goal, though I also recognize the challenges in getting a national form passed by multiple state legislatures.
Q: What are you and your team planning next along these lines of research?
A: We are working on several different lines of research. I am currently co-leading a grant funded by the National Institute on Aging to pragmatically evaluate an Advance Care Planning Specialists program in nursing facilities. We are enthusiastic to partner with long-term care companies who are committed to advance care planning as part of their mission to provide person-centered care. I am also working with colleagues to address the issue of inappropriate use.
Q: What message would you like to leave readers with?
A: Despite these issues we identified, POLST represents a huge improvement over standard practice. In a study we published last year, we found that residents with POLST were three times more likely to have their current preferences documented in the chart than residents without POLST.
POLST is an important tool that supports the provision of person-centered care, but we need to make sure that we have the right conditions in place for it to work as intended.