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Umberfield EE, Fields MC, Lenko R, Morgan TP, Adair ES, Fromme EK, Lum HD, Moss AH, Wenger NS, Sudore RL, Hickman SE. An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go? J Am Med Dir Assoc 2024; 25:557-564.e8. [PMID: 38395413 PMCID: PMC10996838 DOI: 10.1016/j.jamda.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN Integrative review. SETTING AND PARTICIPANTS Not applicable. METHODS We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.
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Affiliation(s)
- Elizabeth E Umberfield
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Fields
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Rachel Lenko
- Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
| | - Teryn P Morgan
- Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
| | | | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
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Wan J, Vaughan A, Shepherd E, Coombs S, Trethewie S, Jaaniste T. Evaluation of paediatric palliative care ambulance plans: A retrospective study. J Child Health Care 2024:13674935231225714. [PMID: 38262591 DOI: 10.1177/13674935231225714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Paediatric Palliative Care Ambulance Plans ('Plans') are used by New South Wales Ambulance (Australia) to support the care needs of children with life-limiting conditions. We aimed to describe the population of children with Plans and provide details regarding Plan completion, paramedic responses during ambulance callouts, and correspondence between Plan recommendations and paramedic responses. Plans lodged in January 2017-December 2019 were retrospectively coded for demographic information, completeness and care preferences. Associated paramedic callout notes (January 2018-December 2019) were coded for paramedic responses. Of 141 Plans retrieved, 38 (41.3% of those providing suggested medications) suggested medication use outside general paramedic scope of practice. Of 199 associated ambulance callouts, reasons for callout included symptom management, planned transfer, death notification and end-of-life care. Over two-thirds of callouts (n = 135, 67.8%) occurred after-hours. Most paramedic callouts (n = 124, 62.3%), excluding planned transfers, resulted in children being transported. Paramedic interventions corresponded with interventions suggested in Plans. However, only 24 (25.3%) of paramedic callout notes documented Plans being sighted. This study provided detailed information about children with palliative care needs for whom Plans were being used, the nature of these Plans and associated paramedic callouts. However, it is not known how paramedics were influenced by Plans.
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Affiliation(s)
- Julianna Wan
- Department of Palliative Care, Sydney Children's Hospital Network, Randwick, NSW, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Elizabeth Shepherd
- Department of Palliative Care, Sydney Children's Hospital Network, Randwick, NSW, Australia
| | - Sandra Coombs
- Department of Palliative Care, Sydney Children's Hospital Network, Randwick, NSW, Australia
| | - Susan Trethewie
- Department of Palliative Care, Sydney Children's Hospital Network, Randwick, NSW, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Tiina Jaaniste
- Department of Palliative Care, Sydney Children's Hospital Network, Randwick, NSW, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
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Bowman JK, Tulsky JA, Ouchi K. Mortality and healthcare resource utilization after cardiac arrest in the United States: A decade of unclear progress and stark disparities. Resuscitation 2023; 193:109985. [PMID: 37778616 DOI: 10.1016/j.resuscitation.2023.109985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Jason K Bowman
- Department of Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care. Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care. Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA; Division of Palliative Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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Mirarchi F, Cammarata C, Cooney TE, Juhasz K, Terman SA. TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care? J Patient Saf 2021; 17:458-466. [PMID: 28622155 DOI: 10.1097/pts.0000000000000387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM). METHODS Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% response rate), resuscitation responses for correct treatment decisions. RESULTS The survey response rate was 85%. Approximately half of emergency medical technician (EMT) respondents were EMT basic, and half EMT respondents were paramedic, with an average age of 42 years. Less than half had previous POLST/LW training averaging 2 hours. Consensus failed to be reached for stand-alone documents. For clinical scenarios, responses to POLST documents specifying do not resuscitate/comfort measures only or cardiopulmonary resuscitation/full treatment exceeded 80% for code status designation and correct resuscitation decisions. Other POLST resuscitation/treatment combinations showed more disparate responses, and most benefited from VM with changes in responses of 20% or more (P ≤ 0.025). Code status responses to LW-based scenarios evidenced a nonconsensus majority (79%-83%) that was significantly affected with VMs (≥12%, P ≤ 0.004); half evidenced large changes in resuscitation decisions (49%, P < 0.001). CONCLUSIONS Document clarity, judged by consensus response, was rarely evidenced. video message/testimonial seems to be a helpful aid to both POLST and LWs. Standardized education and training reveal opportunities to improve patient safety to ensure patient wishes.
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Affiliation(s)
| | | | - Timothy E Cooney
- From the Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Kristin Juhasz
- From the Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
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Baek SK, Kim HJ, Kwon JH, Lee HY, Won YW, Kim YJ, Baik S, Ryu H. Preparation and Practice of the Necessary Documents in Hospital for the "Act on Decision of Life-Sustaining Treatment for Patients at the End-of-Life". Cancer Res Treat 2021; 53:926-934. [PMID: 34082493 PMCID: PMC8524011 DOI: 10.4143/crt.2021.326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/01/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Six forms relating to decisions on life-sustaining treatment (LST) for patients at the end-of-life (EOL) in hospital are required by the “Act on Decision of LST for Patients at the EOL.” We investigated the preparation and creation status of these documents from the database of the National Agency for Management of LST. Materials and Methods We analyzed the contents and details of each document necessary for decisions on LST, and the creation status of forms. We defined patients completing form 1 as “self-determined” of LST, and those whose family members had completed form 11/12 as “family decision” of LST. According to the determination subject, we compared the four items of LST on form 13 (the paper of implementation of LST) and the documentation time interval between forms. Results The six forms require information about the patient, doctor, specialized doctor, family members, institution, decision for LST, and intention to use hospice services. Of 44,381 who had completed at least one document, 36,693 patients had form 13. Among them, 11,531, 10,976, and 12,551 people completed forms 1, 11, and 12, respectively. The documentation time interval from forms 1, 11, or 12 to form 13 was 8.6±13.6 days, 1.0±9.5 days, and 1.5±9.7 days, respectively. Conclusion The self-determination rate of LST was 31% and the mean time interval from self-determination to implementation of LST was 8.6 days. The creation of these forms still takes place when the patients are close to death.
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Affiliation(s)
- Sun Kyung Baek
- Division of Hematology and Oncology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Department of Preventive Medicine, Ulsan University College of Medicine, Seoul, Korea
| | - Jung Hye Kwon
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Chungnam, Korea
| | - Ha Yeon Lee
- Division of Hematology and Oncology, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Young-Woong Won
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yu Jung Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sujin Baik
- Korea National Institute for Bioethics Policy, Seoul, Korea
| | - Hyewon Ryu
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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Brownstein H, Hayes B, Simadri A, Tacey M, Holbeach E. Care to the end: a retrospective observational study of aged care facility residents transferred to hospital in the last day of life. Intern Med J 2020; 51:27-32. [PMID: 33016504 DOI: 10.1111/imj.15084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND While transfer of aged care facility (ACF) residents to an acute hospital is sometimes necessary, for those at end of life this can cause fragmented care and disruption. AIM To explore the characteristics of ACF residents transferred to hospital in the last 24 h of life and factors that might influence this decision, including access to medical review, advance care planning (ACP) and pre-emptive symptom management prescribing, an area not previously researched. METHODS A retrospective observational audit of ACF residents transferred to a metropolitan hospital between 2012 and 2017 who died within 24 h of transfer. RESULTS A total of 149 patients met the criteria. The median age was 87 years, and 63 (42%) were male. Eighty-three (56%) were transferred 'out-of-hours', the majority (71%) having no medical review in the 24 h prior, and 43 (29%) died within 4 h of arrival. The most common reasons for transfer were dyspnoea (46%) and altered conscious state (32%), and the most common cause of death was pneumonia (37%). Some form of ACP documentation was available in 48%. Of the 86 (58%) patients who required injectable opioid for symptom management in hospital, only 7 (8%) had this pre-emptively prescribed on their ACF medication chart. CONCLUSIONS Appropriate decision-making around hospital transfers and end-of-life care for ACF residents may be influenced by access to professionals able to diagnose dying and access to appropriate symptom management medications. ACP is important, but often requires the aforementioned to be enacted. Further research is needed to better inform how we can identify and meet the end-of-life care needs of this cohort.
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Affiliation(s)
| | | | | | - Mark Tacey
- Northern Health, Melbourne, Victoria, Australia.,Melbourne University, Melbourne, Victoria, Australia
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Lee RY, Modes ME, Sathitratanacheewin S, Engelberg RA, Curtis JR, Kross EK. Conflicting Orders in Physician Orders for Life-Sustaining Treatment Forms. J Am Geriatr Soc 2020; 68:2903-2908. [PMID: 32936447 DOI: 10.1111/jgs.16828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/17/2020] [Accepted: 08/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVES Many older persons with chronic illness use Physician Orders for Life-Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders. DESIGN Retrospective cohort study. SETTING Large academic health system. PARTICIPANTS A total of 3,123 POLST users with chronic life-limiting illness who died between 2010 and 2015 (mean age = 69.7 years). MEASUREMENTS In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions. RESULTS Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to "attempt CPR" paired with orders for "limited interventions" or "comfort measures only"; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non-comfort-only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18-1.36; P < .001). CONCLUSION Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.
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Affiliation(s)
- Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Matthew E Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Dundin A, Siegert C, Miller D, Ouchi K, Lakin JR, Bernacki R, Sciacca K. A Pivot to Palliative: An Interdisciplinary Program Development in Preparation for a Coronavirus Patient Surge in the Emergency Department. J Emerg Nurs 2020; 46:760-767.e1. [PMID: 33023790 PMCID: PMC7442908 DOI: 10.1016/j.jen.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/21/2022]
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Electronic medical orders for life-sustaining treatment in New York State: Length of stay, direct costs in an ICU setting. Palliat Support Care 2020; 17:584-589. [PMID: 30636653 DOI: 10.1017/s1478951518000822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In the United States, approximately 20% patients die annually during a hospitalization with an intensive care unit (ICU) stay. Each year, critical care costs exceed $82 billion, accounting for 13% of all inpatient hospital costs. Treatment of sepsis is listed as the most expensive condition in US hospitals, costing more than $20 billion annually. Electronic Medical Orders for Life-Sustaining Treatment (eMOLST) is a standardized documentation process used in New York State to convey patients' wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments. No study to date has looked at the effect of eMOLST as an advance care planning tool on ICU and hospital costs using estimates of direct costs. The objective of our study was to investigate whether signing of eMOLST results in any reduction in length of stay and direct costs for a community-based hospital in New York State. METHOD A retrospective chart review was conducted between July 2016 and July 2017. Primary outcome measures included length of hospital stay, ICU length of stay, total direct costs, and ICU costs. Inclusion criteria were patients ≥65 years of age and admitted into the ICU with a diagnosis of sepsis. An independent samples t test was used to test for significant differences between those who had or had not completed the eMOLST form. RESULT There were no statistical differences for patients who completed or did not complete the eMOLST form on hospital's total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU. SIGNIFICANCE OF RESULTS Completing an eMOLST form did not have any effect on reducing total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.
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Levy C, Ersek M, Scott W, Carpenter JG, Kononowech J, Phibbs C, Lowry J, Cohen J, Foglia M. Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans' Care Preferences. J Gen Intern Med 2020; 35:1803-1812. [PMID: 32096084 PMCID: PMC7280392 DOI: 10.1007/s11606-020-05697-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/31/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set. OBJECTIVE Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion. DESIGN Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score. SUBJECTS All veterans with VA utilization between July 1, 2018, and January 31, 2019. MAIN MEASURES Completed LST templates, goals and LST preferences, and predictors of documentation. RESULTS LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation. CONCLUSIONS LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain VA Medical Center, Aurora, CO, USA.
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Mary Ersek
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Joan G Carpenter
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jennifer Kononowech
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Jill Lowry
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
| | - Jennifer Cohen
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Marybeth Foglia
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA
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11
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Baker A, Speroni KG, Honigsberg H, Ruby D. Healthcare professionals' perceptions of life-sustaining treatment orders. Nursing 2020; 50:64-69. [PMID: 31977809 DOI: 10.1097/01.nurse.0000615132.39081.c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Alyssa Baker
- At the University of Maryland Shore Regional Health in Easton, Md., Karen Gabel Speroni is chair of the Nursing Research Council; Dawn Ruby is a clinical coordinator; and Alyssa Baker is a transitional nurse navigator, as well as a clinical hospice nurse with Talbot Hospice. Hope Honigsberg is a family practice NP at University of Maryland Shore Medical Group
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12
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Mirarchi FL, Juhasz K, Cooney TE, Puller J, Kordes T, Weissert L, Lewis ML, Intrieri B, Cook N. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records. J Patient Saf 2019; 15:230-237. [PMID: 31449196 PMCID: PMC6728055 DOI: 10.1097/pts.0000000000000631] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders. METHODS We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA. RESULTS Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients. CONCLUSIONS Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.
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Clemency BM, Grimm KT, Lauer SL, Lynch JC, Pastwik BL, Lindstrom HA, Dailey MW, Waldrop DP. Transport Home and Terminal Extubation by Emergency Medical Services: An Example of Innovation in End-of-Life Care. J Pain Symptom Manage 2019; 58:355-359. [PMID: 30904415 DOI: 10.1016/j.jpainsymman.2019.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
Abstract
For most terminally ill patients, the preferred place of death is home. Previous literature has demonstrated the feasibility of at-home terminal extubation performed by critical care and hospice physicians. This case report describes a terminal extubation performed by a paramedic under the direct supervision of an Emergency Medical Services physician in the patient's home. Guided by a comprehensive plan and logistical support from a team of hospice providers, a successful out-of-hospital terminal extubation is possible. To truly achieve patient-centered care at end of life, the choice for an out-of-hospital death is necessary.
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Affiliation(s)
- Brian M Clemency
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Erie County Medical Center, Buffalo, New York, USA.
| | - Kathleen T Grimm
- Erie County Medical Center, Buffalo, New York, USA; Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Jenna C Lynch
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Benjamin L Pastwik
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Heather A Lindstrom
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Michael W Dailey
- Department of Emergency Medicine, Albany Medical Center, Albany, New York, USA
| | - Deborah P Waldrop
- School of Social Work, University at Buffalo, Buffalo, New York, USA
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14
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The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department. Ann Emerg Med 2019; 75:171-180. [PMID: 31248675 DOI: 10.1016/j.annemergmed.2019.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.
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15
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Turnbull AE, Ning X, Rao A, Tao JJ, Needham DM. Demonstrating the impact of POLST forms on hospital care requires information not contained in state registries. PLoS One 2019; 14:e0217113. [PMID: 31211788 PMCID: PMC6581427 DOI: 10.1371/journal.pone.0217113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/30/2019] [Indexed: 11/18/2022] Open
Abstract
Background Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging. Objectives To demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects. Design Prospective cohort study. Setting and participants Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission. Results Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10). Conclusion Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.
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Affiliation(s)
- Alison E. Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Johns Hopkins University, Outcomes After Critical Illness and Surgery Group (OACIS), Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Xuejuan Ning
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Anirudh Rao
- Medstar Washington Hospital, Washington, DC, United States of America
| | - Jessica J. Tao
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Dale M. Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Johns Hopkins University, Outcomes After Critical Illness and Surgery Group (OACIS), Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, United States of America
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16
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Elderly patients presenting to a Level I trauma center with Physician Orders for a Life-Sustaining Treatment form: A propensity-matched analysis. J Trauma Acute Care Surg 2019; 87:153-160. [DOI: 10.1097/ta.0000000000002321] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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17
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Abbott J. The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department. Ann Emerg Med 2018; 73:294-301. [PMID: 30503382 DOI: 10.1016/j.annemergmed.2018.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/06/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.
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Affiliation(s)
- Jean Abbott
- Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora, CO.
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18
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Waldrop DP, McGinley JM, Clemency B. The Nexus Between the Documentation of End-of-Life Wishes and Awareness of Dying: A Model for Research, Education and Care. J Pain Symptom Manage 2018; 55:522-529. [PMID: 28919539 DOI: 10.1016/j.jpainsymman.2017.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/07/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
The convergence of medical treatment that can extend life with written medical orders that make it possible to refuse such treatment brings the differential dynamics of contemporary end-of-life decision making into sharp focus. Communication between families and clinicians can be confusing, uncertain, and pressured when death is imminent. These situations create distress that ultimately influences the end-of-life experience for people who are dying and those who care for them. This article presents the analysis of the decisional dynamics that emerge from the intersection of the patient-family-provider awareness that death is near with the presence or absence of documentation of expressed wishes for end-of-life care. A heuristic analysis was conducted with data from three studies about urgent decision making at the end of life. Original study data included 395 surveys, in-depth interviews with 91 prehospital (paramedics and emergency medical technicians), and content analysis of 100 Medical Orders for Life Sustaining Treatment forms that led to the development of an overarching conceptual model of decision making. Four decisional contexts emerged from the intersection of awareness of dying and documentation of wishes: 1) Aware Documented, 2) Aware Undocumented, 3) Unaware Documented, and 4) Unaware Undocumented. This generalizable model, which is agnostic of setting, can help clinicians more astutely recognize the clinical situation when death is imminent, assess patients and caregivers, and intervene to help focus conversation and direct decision making. The model can also inform research, education, and care for people in some of the most vulnerable moments of life.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, Buffalo, New York, USA.
| | | | - Brian Clemency
- Emergency Medicine Department, Erie County Medical Center, Buffalo, New York, USA
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19
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Johnson SB, Butow PN, Kerridge I, Bell ML, Tattersall MHN. How Well Do Current Measures Assess the Impact of Advance Care Planning on Concordance Between Patient Preferences for End-of-Life Care and the Care Received: A Methodological Review. J Pain Symptom Manage 2018; 55:480-495. [PMID: 28943359 DOI: 10.1016/j.jpainsymman.2017.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/04/2017] [Accepted: 09/04/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Research has begun to focus on whether Advance Care Planning (ACP) has the capacity to influence care, and to examine whether ACP can be effective in meeting patients' wishes at the end of their lives. Little attention has been paid, however, to the validity and clinical relevance of existing measures. METHODS A search of Medline and CINHAL identified ACP studies measuring concordance between end-of-life (EoL) preferences and the care received. Databases were searched from 2000 to August 2016. We developed a checklist to evaluate the quality of included studies. Data were collected on the proportion of patients who received concordant care, extracted from manuscript tables or calculated from the text. OUTCOMES Of 2941 papers initially identified, nine eligible studies were included. Proportions of patients who received concordant care varied from 14% to 98%. Studies were heterogeneous and methodologically poor, with limited attention paid to bias/external validity. Studies varied with regards to design of measures, the meaning of relevant terms like "preference" "EoL care" and "concordance," and the completeness of reported data. CONCLUSION Methodological variations and weaknesses compromise the validity of study results, and prevent meaningful comparisons between studies or synthesis of the results. Effectively evaluating whether ACP interventions enhance a patient's capacity to receive the care they want requires harmonization of research. This demands standardization of methods across studies, validating of instruments, and consensus based on a consistent conceptual framework regarding what constitutes a meaningful outcome measure.
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20
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Morley JE. A Decade of JAMDA. J Am Med Dir Assoc 2017; 18:993-997. [PMID: 29169742 DOI: 10.1016/j.jamda.2017.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Affiliation(s)
- John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO.
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21
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Stuart RB, Thielke S. Standardizing Protection of Patients' Rights From POLST to MOELI (Medical Orders for End-of-Life Intervention). J Am Med Dir Assoc 2017. [DOI: 10.1016/j.jamda.2017.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Moss AH, Zive DM, Falkenstine EC, Dunithan C. The Quality of POLST Completion to Guide Treatment: A 2-State Study. J Am Med Dir Assoc 2017; 18:810.e5-810.e9. [PMID: 28668665 DOI: 10.1016/j.jamda.2017.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 05/18/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Physician Orders for Life-Sustaining Treatment (POLST) need to be complete and consistent to allow health care personnel to honor patient preferences in a time of emergency. The purpose of our study was to evaluate the quality of POLST completion to guide treatment for level of medical intervention. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study combined data from the Oregon and West Virginia POLST registries for the study period January 1, 2010, through December 31, 2016. All POLST form resuscitation (section A) and level of medical intervention (section B) orders were reviewed. MEASUREMENTS Percent of POLST form orders in sections A and B with and without contradictions. RESULTS During the study period, there were 268,386 POLST forms in the Oregon POLST Registry and 10,122 forms in the West Virginia e-Directive Registry. Of the forms, 99.2% in Oregon and 96.6% in West Virginia contained orders in both sections A and B. There were contradictions on 0.11% of forms from Oregon and 2.53% from West Virginia. CONCLUSIONS The quality of POLST form completion in the Oregon and West Virginia registries is good with less than 10% of forms lacking orders in sections A and B and containing contradictory orders. This study indicates what type of results are possible with statewide education, likely through POLST Paradigm Programs. Further research is needed to determine the quality of POLST form completion in other states and other factors that contribute to their quality.
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Affiliation(s)
- Alvin H Moss
- Center for Health Ethics and Law, West Virginia University, Morgantown, WV.
| | - Dana M Zive
- Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, OR
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23
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Response to Clemency et al: Significant Errors, Gaps in MOLST Process, and Opportunities for Improvement With eMOLST. J Am Med Dir Assoc 2017; 18:182-184. [DOI: 10.1016/j.jamda.2016.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/08/2016] [Indexed: 11/21/2022]
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Clemency BM, Basior JM, Lindstrom HA, Cordes CC, Waldrop DP. The Realities of Operationalizing MOLST Forms in Emergency Situations. J Am Med Dir Assoc 2017; 18:184-186. [DOI: 10.1016/j.jamda.2016.11.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 11/15/2022]
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