An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go?

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.

Core Competencies for Serious Illness Conversations: An Integrative Systematic Review

Objective: The Serious Illness Care Program was developed to support goals and values discussions between seriously ill patients and their clinicians. The core competencies, that is, the essential clinical conversation skills that are described as requisite for effective serious illness conversations (SICs) in practice, have not yet been explicated. This integrative systematic review aimed to identify core competencies for SICs in the context of the Serious Illness Care Program. Methods: Articles published between January 2014 and March 2023 were identified in MEDLINE, PsycINFO, CINAHL, and PubMed databases. In total, 313 records underwent title and abstract screening, and 96 full-text articles were assessed for eligibility. The articles were critically appraised using the Joanna Briggs Institute Critical Appraisal Guidelines, and data were analyzed using thematic synthesis. Results: In total, 53 articles were included. Clinicians' core competencies for SICs were described in 3 themes: conversation resources, intrapersonal capabilities, and interpersonal capabilities. Conversation resources included using the conversation guide as a tool, together with applying appropriate communication skills to support better communication. Intrapersonal capabilities included calibrating one's own attitudes and mindset as well as confidence and self-assurance to engage in SICs. Interpersonal capabilities focused on the clinician's ability to interact with patients and family members to foster a mutually trusting relationship, including empathetic communication with attention and adherence to patient and family members views, goals, needs, and preferences. Conclusions: Clinicians need to efficiently combine conversation resources with intrapersonal and interpersonal skills to successfully conduct and interact in SICs.

Core elements of serious illness conversations: an integrative systematic review

BACKGROUND

Ariadne Labs' Serious Illness Care Program (SICP), inclusive of the Serious Illness Conversation Guide (SICG), has been adapted for use in a variety of settings and among diverse population groups. Explicating the core elements of serious illness conversations could support the inclusion or exclusion of certain components in future iterations of the programme and the guide.

AIM

This integrative systematic review aimed to identify and describe core elements of serious illness conversations in relation to the SICP and/or SICG.

DESIGN

Literature published between 1 January 2014 and 20 March 2023 was searched in MEDLINE, PsycINFO, CINAHL and PubMed. All articles were evaluated using the Joanna Briggs Institute Critical Appraisal Guidelines. Data were analysed with thematic synthesis.

RESULTS

A total of 64 articles met the inclusion criteria. Three themes were revealed: (1) serious illness conversations serve different functions that are reflected in how they are conveyed; (2) serious illness conversations endeavour to discover what matters to patients and (3) serious illness conversations seek to align what patients want in their life and care.

CONCLUSIONS

Core elements of serious illness conversations included explicating the intention, framing, expectations and directions for the conversation. This encompassed discussing current and possible trajectories with a view towards uncovering matters of importance to the patient as a person. Preferences and priorities could be used to inform future preparation and recommendations. Serious illness conversation elements could be adapted and altered depending on the intended purpose of the conversation.

Testing the What Matters to Me workbook in a diverse sample of seriously ill patients and caregivers

Objectives

We evaluated the What Matters to Me Workbook, a patient-facing version of the Serious Illness Conversation Guide co-created by Ariadne Labs and The Conversation Project.

Methods

We purposively recruited diverse seriously ill patients and caregivers in the US. Participants completed the Workbook, a survey, and a semi-structured in-depth interview about their experience. Qualitative analysis of interviews and notes was employed to extract themes. Simple descriptive statistics were employed to analyze eight investigator authored questions.

Results

Twenty-nine study participants completed twenty-one interviews and twenty-five surveys. Ratings for safety (3.87/4, SD = 0.43) and acceptability (3.59/4, SD = 0.956) were higher than ratings for ease of use (3.30/4, SD = 0.97) and usefulness (3.24/4, SD = 0.80). Qualitative analysis identified that while the workbook was safe, acceptable, easy to use, and useful, it is more important who is recommending it and how they are explaining it.

Conclusion

If presented in the right way by a trustworthy person, the What Matters to Me Workbook can be an easy to use, useful, and safe resource for patients with serious illness and their caregivers.

Innovation

The Workbook focuses on serious illness rather than end-of-life and meshes with a clinician-facing conversation guide and a health-system level intervention.

Lessons Learned About System-Level Improvement in Serious Illness Communication: A Qualitative Study of Serious Illness Care Program Implementation in Five Health Systems

BACKGROUND

Serious illness communication is a key element of high-quality care, but it is difficult to implement in practice. The Serious Illness Care Program (SICP) is a multifaceted intervention that contributes to more, earlier, and better serious illness conversations and improved patient outcomes. This qualitative study examined the organizational and implementation factors that influenced improvement in real-world contexts.

METHODS

The authors performed semistructured interviews of 30 health professionals at five health systems that adopted SICP as quality improvement initiatives to investigate the organizational and implementation factors that appeared to influence improvement.

RESULTS

After SICP implementation across the organizations studied, approximately 4,661 clinicians have been trained in serious illness communication and 56,712 patients had had an electronic health record (EHR)-documented serious illness conversation. Facilitators included (1) visible support from leaders, who financially invested in an implementation team and champions, expressed the importance of serious illness communication as an institutional priority, and created incentives for training and documenting serious illness conversations; (2) EHR and data infrastructure to foster performance improvement and accountability, including an accessible documentation template, a reporting system, and customized data feedback for clinicians; and (3) communication skills training and sustained support for clinicians to problem-solve communication challenges, reflect on communication experiences, and adapt the intervention. Inhibitors included leadership inaction, competing priorities and incentives, variable clinician acceptance of EHR and data tools, and inadequate support for clinicians after training.

CONCLUSION

Successful implementation appeared to rely on multilevel organizational strategies to prioritize, reward, and reinforce serious illness communication. The insights derived from this research may function as an organizational road map to guide implementation of SICP or related quality initiatives.

Advance Care Planning in the United States: A 2023 review

Advance Care Planning (ACP) in the US is complex due in part to a lack of a unified health care system, though more recent policy changes permitting reimbursement for ACP conversations offer some hope. One key barrier to ACP is public perceptions of ACP, made worse by a historical focus on messaging that is unappealing and does not meet people's need to focus on the present before contemplating the future. As we learn more about how to engage the public, there is also increasing recognition that the previous focus on making very specific decisions about the future needs to shift to a focus on preparing people for communication and decision making. Numerous programs exist for health care professionals to support meaningful explorations of goals, values, and preferences, and there is growing availability of resources to support this work, both in the community and health care setting. Further research is needed to understand the full complexity of ACP implementation and to identify person-centred outcomes to support high quality ACP.

Improving serious illness communication: a qualitative study of clinical culture

OBJECTIVE

Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations.

METHODS

Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions.

RESULTS

We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes.

CONCLUSIONS

Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.

Decision-making conversations for life-sustaining treatment with seriously ill patients using a Danish version of the US POLST: a qualitative study of patient and physician experiences

OBJECTIVE

To explore patients' and physicians' perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form.

DESIGN

Semi-structured interviews following a conversation about preferences for life-sustaining treatment.

SETTING

Danish hospitals, nursing homes, and general practitioners' clinics.

SUBJECTS

Patients and physicians.

MAIN OUTCOME MEASURES

Qualitative analyses of interview data.

FINDINGS

After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy.

CONCLUSION

Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges.KEY POINTSConversations about preferences for life-sustaining treatment are important, but not performed systematically.When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements.Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care.Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

Serious Illness Care Programme-contextual factors and implementation strategies: a qualitative study

OBJECTIVES

The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients' values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three 'real-world' health system SICP initiatives.

METHODS

We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey.

RESULTS

Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians' attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities.

CONCLUSIONS

Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.

Decreasing Trends in Opioid Prescribing on Discharge to Hospice Care

CONTEXT

There are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life.

OBJECTIVE

We assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care.

METHODS

This was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients' electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care).

RESULTS

Among 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%-94.1%) in 2010 to 79.3% (95% CI = 74.3%-83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period.

CONCLUSIONS

We observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care.

Shared Medication PLanning In (SIMPLIfy) Home Hospice: An Educational Program to Enable Goal-Concordant Prescribing In Home Hospice

CONTEXT

Simplifying medication regimens by tapering and/or withdrawing unnecessary drugs is important to optimize quality of life and safety for patients with serious illness. Few resources are available to educate clinicians, patients and family caregivers about this process.

OBJECTIVE

To describe the development of an educational program called Shared Medication PLanning In (SIMPLIfy) Home Hospice.

METHODS

An environmental scan identified a state-of-the-art educational program for home hospice deprescribing that we adapted using a stakeholder panel engagement process. The stakeholder panel (two hospice administrators, three nurses, two physicians, two pharmacists, and two former family caregivers) drawn from two geographically diverse hospice agencies reviewed the educational program and recommended additional content.

RESULTS

Iterative rounds of review and feedback resulted in: 1) a three-part clinician educational program (total duration = 1.5 hour) that presents a standardized, goal-concordant, medication review approach to align medications and conversations about regimen simplification with patient and family caregiver goals of care; 2) a patient-family caregiver medication management educational notebook that presents common symptoms, hospice medications, and medication regimen simplification principles; and 3) a brief guide including helpful phrases to use as conversation starters for key steps in the program. A professional designer created thematic coherence for all materials that was well received by stakeholder panelists and hospice staff.

CONCLUSION

Educational materials can support hospice programs' and clinicians' efforts to implement goal-concordant medication simplification that optimizes end-of-life outcomes for patients and family caregivers. Evaluation of outcomes including medication appropriateness and family caregiver medication administration burden are not yet available.

Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration

Importance

Palliative care is a patient-centered approach associated with improvements in quality of life; however, results regarding its association with a survival benefit have been mixed, which may be a factor in its underuse.

Objective

To assess whether early palliative care is associated with a survival benefit among patients with advanced lung cancer.

Design, Setting, and Participants

This retrospective population-based cohort study was conducted among patients with lung cancer who were diagnosed with cancer between January 1, 2007, and December 31, 2013, with follow-up until January 23, 2017. Participants comprised 23 154 patients with advanced lung cancer (stage IIIB and stage IV) who received care in the Veterans Affairs health care system. Data were analyzed from February 15, 2019, to April 28, 2019.

Exposure

Palliative care defined as a specialist-delivered palliative care encounter received after lung cancer diagnosis.

Main Outcomes and Measures

The primary outcome was survival. The association between palliative care and place of death was also examined. Propensity score and time-varying covariate methods were used to calculate Cox proportional hazards and to perform regression modeling.

Results

Of the 23 154 patients enrolled in the study, 57% received palliative care. The mean (SD) age of participants was 68 (9.5) years, and 98% of participants were men. An examination of the timing of palliative care receipt relative to cancer diagnosis found that palliative care received 0 to 30 days after diagnosis was associated with decreases in survival (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.97-2.30), palliative care received 31 to 365 days after diagnosis was associated with increases in survival (aHR, 0.47; 95% CI, 0.45-0.49), and palliative care received more than 365 days after diagnosis was associated with no difference in survival (aHR, 1.00; 95% CI, 0.94-1.07) compared with nonreceipt of palliative care. Receipt of palliative care was also associated with a reduced risk of death in an acute care setting (adjusted odds ratio, 0.57; 95% CI, 0.52-0.64) compared with nonreceipt of palliative care.

Conclusions and Relevance

The results suggest that palliative care was associated with a survival benefit among patients with advanced lung cancer. Palliative care should be considered a complementary approach to disease-modifying therapy in patients with advanced lung cancer.

Measuring Goal-Concordant Care: Results and Reflections From Secondary Analysis of a Trial to Improve Serious Illness Communication

CONTEXT

Many consider goal-concordant care (GCC) to be the most important of advance care planning and palliative care. Researchers face significant challenges in attempting to measure this outcome. We conducted a randomized controlled trial to assess the effects of a system-level intervention to improve serious illness communication on GCC and other outcomes.

OBJECTIVES

To describe our measurement approach to GCC, present findings from a post-hoc analysis of trial data, and discuss lessons learned about measuring GCC.

METHODS

Using trial data collected to measure GCC, we analyzed ratings and rankings from a nonvalidated survey of patient priorities in the setting of advanced cancer, the Life Priorities Scale, and compared outcomes with correlative measures.

RESULTS

Participants commonly rated several predetermined and literature-derived priorities as important but did so in ways that were commonly incongruent with rankings. Ratings were frequently stable over time; rankings less so. Rankings are more likely to help assess the degree to which care is goal concordant but may be best augmented by corollary measures that signal achievement of a given priority.

CONCLUSION

Measuring GCC remains a fundamental challenge to palliative care researchers. Ratings attest to the fact that many things matter to patients; however, rankings can better determine what matters most. Insights gained from our experience may guide future research aiming to use this outcome to assess the effect of intervention to improve serious illness care.

Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer

Background: Serious illness conversations are part of advance care planning (ACP) and focus on prognosis, values, and goals in patients who are seriously ill. To be maximally effective, such conversations must be documented accurately and be easily accessible. Objectives: The two coprimary objectives of the study were to assess concordance between written documentation and recorded audiotaped conversations, and to evaluate adherence to the Serious Illness Conversation Guide questions. Methods: Data were obtained as part of a trial in patients with advanced cancer. Clinicians were trained to use a guide to conduct and document serious illness conversations. Conversations were audiotaped. Two researchers independently compared audiorecordings with the corresponding documentation in an electronic health record (EHR) template and free-text progress notes, and rated the degree of concordance and adherence. Results: We reviewed a total of 25 audiorecordings. Clinicians addressed 87% of the conversation guide elements. Prognosis was discussed least frequently, only in 55% of the patients who wanted that information. Documentation was fully concordant with the conversation 43% of the time. Concordance was best when documenting family matters and goals, and least frequently concordant when documenting prognostic communication. Most conversations (64%) were documented in the template, a minority (28%) only in progress notes and two conversations (8%) were not documented. Concordance was better when the template was used (62% vs. 28%). Conclusion: Clinicians adhered well to the conversation guide. However, key information elicited was documented and fully concordant less than half the time. Greater concordance was observed when clinicians used a prespecified template. The combined use of a guide and EHR template holds promise for ACP conversations.

Effect of the Serious Illness Care Program on Health Care Utilization at the End of Life for Patients with Cancer

Objectives: To determine the effect of the Serious Illness Care Program on health care utilization at the end of life in oncology. Design: Analysis of the secondary outcome of health care utilization as part of a cluster-randomized clinical trial that ran from 2012 to 2016. Clinicians in the intervention group received training, coaching, and system supports to have discussions with patients using a Serious Illness Conversation Guide (SICG); clinicians in the control arm followed usual care. Setting/Subject: Patients with advanced cancer who died within two years of enrollment at the Dana-Farber Cancer Institute. Measurement: Health care utilization was abstracted from the electronic medical record using the National Quality Forum (NQF)-endorsed indicators of aggressive cancer care at the end of life and scored from 0 to 6 (one point for each aggressive indicator); t tests and chi-square tests were used to determine differences between intervention and control patients. Results: The charts of 159 patients who died were reviewed. Neither the main outcome of mean number of aggressive indicators (0.9 vs. 0.9, p = 0.84) nor the proportion of patients with any aggressive care (49% intervention [95% CI: 40-57] vs. 54% control [95% CI: 42-67]) differed between patients in the intervention and control groups. Conclusion: In this analysis of a secondary outcome from a randomized clinical trial of the Serious Illness Care Program, intervention and control patients had similar end-of-life health care utilization as measured by the mean number of NQF-endorsed indicators. Future research efforts should focus on studying the strategies by which communication about patients' prognosis, values, and goals leads to personalized care plans.

Quality Measurement of Serious Illness Communication: Recommendations for Health Systems Based on Findings from a Symposium of National Experts

Background: Communication between clinicians and patients fundamentally shapes the experience of serious illness. There is increasing recognition that health systems should routinely implement structures and processes to assure high-quality serious illness communication (SIC) and measure the effectiveness of their efforts on key outcomes. The absence, underdevelopment, or limited applicability of quality measures related specifically to SIC, and their limited application only to those seen by specialist palliative and hospice care teams, hinder efforts to improve care planning, service delivery, and health outcomes for all seriously ill patients. Objective: We convened an expert stakeholder symposium and subsequently surveyed participants to consider challenges, opportunities, priorities, and strategies to improve quality measurement specific to SIC. Results: We identified several barriers and opportunities to improving quality measurement of SIC. These include issues related to the definition of SIC, methodological challenges related to measuring SIC and related outcomes, underutilization of technologies that can facilitate measurement, and measurement development, and dissemination. Conclusions: Patients, clinicians, and health systems increasingly align around the importance of high-quality communication in serious illness. We offer recommendations for various stakeholder groups to advance SIC quality measurement. Enthusiasm and a sense of urgency among health systems to drive and measure communication improvements inform our proposal for a set of example measures for implementation now.

Earlier identification of seriously ill patients: an implementation case series

OBJECTIVE

To describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values.

METHODS

We present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP).

RESULTS

Five sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the 'Surprise Question'), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning-based analytical approaches.

CONCLUSIONS

Involving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients-those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.

A Resident-Led Initiative to Increase Documentation of Surrogate Decision Makers for Hospitalized Patients

BACKGROUND

Identification of surrogate decision makers (SDMs) is an important part of advance care planning for hospitalized patients. Despite its importance, the best methods for engaging residents to sustainably improve SDM documentation have not been identified.

OBJECTIVE

We implemented a hospital-wide quality improvement initiative to increase identification and documentation of SDMs in the electronic health record (EHR) for hospitalized patients, utilizing a Housestaff Quality and Safety Council (HQSC).

METHODS

EHR documentation of SDMs for all adult patients admitted to a tertiary academic hospital, excluding psychiatry, were tracked and grouped by specialty in a weekly run chart during the intervention period (July 2015 through April 2016). This also continued postintervention. Interventions included educational outreach for residents, monthly plan-do-study-act cycles based on performance feedback, and a financial incentive of a one-time payment of 0.75% of a resident's salary put into the retirement account of each resident, contingent on meeting an SDM documentation target. Comparisons were made using statistical process control and chi-square tests.

RESULTS

At baseline, SDMs were documented for 11.1% of hospitalized adults. The intervention period included 9146 eligible admissions. Hospital-wide SDM documentation increased significantly and peaked near the financial incentive deadline at 48% (196 of 407 admissions, P < 001). Postintervention, hospital-wide SDM documentation declined to 30% (134 of 446 admissions, P < .001), but remained stable.

CONCLUSIONS

This resident-led intervention sustainably increased documentation of SDMs, despite a decline from peak rates after the financial incentive period and notable differences in performance patterns by specialty admitting service.

Enhancing Advance Care Planning Conversations by Nurses in a Bone Marrow Transplantation Unit

OBJECTIVES

To describe the impact of advance care planning (ACP) education on nurses' confidence in ACP knowledge and practice and to identify barriers to facilitate ACP conversation in a bone marrow transplantation unit.

SAMPLE & SETTING

60 nurses working in the bone marrow transplant unit at Oregon Health and Science University, an academic medical center.

METHODS & VARIABLES

The aim of this quality improvement project was to increase ACP conversations by nurses. The authors used a single-group pre-/post-test design to assess the effectiveness of a 30-minute educational intervention in changing nurses' confidence and practice. Group interviews were conducted to identify barriers to ACP.

RESULTS

The educational intervention increased nurses' confidence in knowledge about ACP. The number of nurses who discussed ACP with patients also increased, but it was not statistically significant. Lack of time, inefficient workflow, and concerns about questioning providers' understanding of patient preferences were identified as barriers for nurses engaging in and documenting ACP conversations.

IMPLICATIONS FOR NURSING

In addition to appropriate education, strategies that help tailor ACP practice to fit into nurse workflow and promote collaboration with other healthcare team members are needed to change nurses' ACP practice.

A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer

Background: Conversations with seriously ill patients about their values and goals have been associated with reduced distress, a better quality of life, and goal-concordant care near the end of life. Yet, little is known about how such conversations are conducted. Objective: To characterize the content of serious illness conversations and identify opportunities for improvement. Design: Qualitative analysis of audio-recorded, serious illness conversations using an evidence-based guide and obtained through a cluster randomized controlled trial in an outpatient oncology setting. Setting/Measurements: Clinicians assigned to the intervention arm received training to use the "Serious Illness Conversation Guide" to have a serious illness conversation about values and goals with advanced cancer patients. Conversations were de-identified, transcribed verbatim, and independently coded by two researchers. Key themes were analyzed. Results: A total of 25 conversations conducted by 16 clinicians were evaluated. The median conversation duration was 14 minutes (range 4-37), with clinicians speaking half of the time. Thematic analyses demonstrated five key themes: (1) supportive dialogue between patients and clinicians; (2) patients' openness to discuss emotionally challenging topics; (3) patients' willingness to articulate preferences regarding life-sustaining treatments; (4) clinicians' difficulty in responding to emotional or ambiguous patient statements; and (5) challenges in discussing prognosis. Conclusions: Data from this exploratory study suggest that seriously ill patients are open to discussing values and goals with their clinician. Yet, clinicians may struggle when disclosing a time-based prognosis and in responding to patients' emotions. Such skills should be a focus for additional training for clinicians caring for seriously ill patients.

Changes Over Time in the Oregon Physician Orders for Life-Sustaining Treatment Registry: A Study of Two Decedent Cohorts

Background: The Physician Orders for Life-Sustaining Treatment (POLST) began in Oregon in 1993 and has since spread nationally and internationally.

Objectives: Describe and compare demographics and POLST orders in two decedent cohorts: deaths in 2010–2011 (Cohort 1) and in 2015–2016 (Cohort 2).

Design: Descriptive retrospective study.

Setting/Subjects: Oregon decedents with an active form in the Oregon POLST Registry.

Measurements: Oregon death records were matched with POLST orders. Descriptive analysis and logistic regression models assess differences between the cohorts.

Results: The proportion of Oregon decedents with a registered POLST increased by 46.6% from 30.9% (17,902/58,000) in Cohort 1 to 45.3% (29,694/65,458) in Cohort 2. The largest increase (83.3%) was seen in decedents 95 years or older with a corresponding 78.7% increase in those with Alzheimer's disease and dementia, while the interval between POLST form completion and death in these decedents increased from a median of 9–52 weeks. Although orders for do not resuscitate and other orders to limit treatment remained the most prevalent in both cohorts, logistic regression models confirm a nearly twofold increase in odds for cardiopulmonary resuscitation and full treatment orders in Cohort 2 when controlling for age, sex, race, education, and cause of death.

Conclusion: Compared with Cohort 1, Cohort 2 reflected several trends: a 46.6% increase in POLST Registry utilization most marked in the oldest old, substantial increases in time from POLST completion to death, and disproportionate increases in orders for more aggressive life-sustaining treatment. Based on these findings, we recommend testing new criteria for POLST completion in frail elders.

Association of Early Palliative Care With Chemotherapy Intensity in Patients With Advanced Stage Lung Cancer: A National Cohort Study

INTRODUCTION

Patients with advanced lung cancer have a poor prognosis, but both chemotherapy and early palliative care (EPC) have been shown to improve survival and quality of life (QOL). The relationship between palliative care and receipt of chemotherapy receipt is understudied. We sought to determine if EPC is associated with chemotherapy receipt and intensity among patients with advanced stage lung cancer.

METHODS

Retrospective cohort study of patients in the national Veterans Health Administration (VA) with stage IIIB or IV lung cancer diagnosed between January 2007- December 2013. EPC was defined as a specialist-delivered palliative care received within 90 days of cancer diagnosis. Outcomes included any chemotherapy receipt and high-intensity chemotherapy receipt defined as: i) more than 4 cycles of a platinum-based doublet, ii) ≥3 lines of chemotherapy, iii) Bevacizumab/Cetuximab triplet therapy, iv) Erlotinib use prior to 2011, and v) chemotherapy in the last days of life. Logistic regression was used to determine the association between EPC and chemotherapy receipt after adjustment for patient and tumor characteristics.

RESULTS

Among the entire cohort (N=23,566), 37% received EPC and 45% received any chemotherapy. Among those with EPC, 34% received chemotherapy compared to 51% among those without EPC (Adjusted Odds Ratio (AOR=0.55, 95% CI: 0.51-0.58). Patients who received EPC had reduced receipt of high-intensity chemotherapy including >4 cycles of platinum-based doublet (AOR=0.68, 95% CI: 0.60-0.77), ≥ 3 lines of chemotherapy (AOR=0.61, 95% CI: 0.53-0.71), triplet therapy (AOR=0.68, 95% CI: 0.56-0.82) and use of erlotinib prior to 2011 (AOR=0.66, 95% CI: 0.55-0.79). Patients with EPC were more likely to receive chemotherapy in the last 14 (AOR=1.65, 95% CI: 1.44-1.87) and 30 days (AOR=1.67, 95% CI: 1.51-1.85) of life compared to those without EPC.

CONCLUSIONS

EPC was associated with reduced receipt of both any chemotherapy and high-intensity chemotherapy. However, receipt of chemotherapy at the very end-of-life was increased among patients with EPC compared to those without EPC. Among patients with advanced lung cancer, EPC may optimize patient selection for chemotherapy receipt leading to reduced use of high-intensity therapy by focusing on quality of life in accordance with patients' performance, preferences and goals of care.

Clinical Intentions of Antibiotics Prescribed Upon Discharge to Hospice Care

OBJECTIVES

To better understand the clinical intentions for antibiotic prescribing upon discharge from acute care to hospice care.

DESIGN

Retrospective cohort study.

SETTING

Five hundred forty-four-bed academic, acute-care, tertiary referral hospital in Portland, Oregon.

PARTICIPANTS

Adults (≥18) who received an outpatient prescription for antibiotics on discharge from an acute care hospital to hospice care between January 1, 2009 and December 31, 2011 (N = 149).

MEASUREMENTS

We determined whether antibiotics were indicated for treatment of an active infection, palliative treatment, prophylaxis, or prescribed according to family or participant preference.

RESULTS

Antibiotics were prescribed to 17.6% (n = 149) of individuals discharged to hospice care over the 3-year study period. Antibiotics were most frequently prescribed for pneumonia (19.5%), urinary tract infections (18.9%), and gastrointestinal tract infections (17.0%). The explicit rationale for antibiotic prescription was documented for only 72 prescriptions (45.3%). For 84 (52.8%) participants, antibiotics were used to treat an active infection in the hospital. Of prescriptions with a documented rationale, 37.5% indicated that the intent was curative, 26.4% prophylaxis, and 22.2% to suppress an infection. For 19.4% of prescriptions, participants or their family members specifically wanted to be treated with antibiotics. Only 9.7% of prescriptions specifically indicated that antibiotics were prescribed for palliative reasons.

CONCLUSION

Antibiotics were frequently prescribed for treatment of active infection in individuals discharged to hospice care. Further research is needed to document antibiotic benefits and risks and optimize medication management at the end of life.

Implementation of group visits to improve outpatient oncology advance care planning

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Background: Oncology patients that participate in advance care planning (ACP) and complete advance directives (AD) are more likely to receive goal-concordant end of life care. The AD documentation rate within our academically-affiliated community outpatient oncology clinic is below national and institutional averages. A group medical visit effectively facilitated ACP in a geriatric primary care setting. This quality improvement project implemented a similar ACP conversation group (ACPCG) in an outpatient oncology setting. Methods: Adult patients in a community oncology clinic were contacted and invited to participate in ACPCG by a nurse practitioner who works in the clinic. Using a facilitation guide, the 2-session intervention included sharing past ACP experiences, identifying surrogate decision makers, starting conversations, and discussing surrogate flexibility. Recruitment, retention, and patient ACP outcomes were measured. Results: Seventy-six patients were successfully contacted and seventeen signed up (22% recruitment rate). Twelve patients participated in the first session, and five attended the second session (42% retention). Recruitment was time intensive, and several patients responded that ACP was not relevant to their situation. Six participants completed an AD prior to attending the first session (50%) but only one had an AD in their medical record. Two had surrogate decision makers documented prior to the intervention (16%). Participants reported the ACPCG as helpful in making the process less overwhelming. There was no increase in AD documentation rates within the medical record four weeks after the intervention, but the rate of surrogate documentation increased to seven (58%). Conclusions: Participants had higher than average rates of AD completion prior to the intervention but had not shared the document with their providers. While the ACPCG was well received by patients, implementation faced multiple challenges. More efficient recruitment methods and strategies to facilitate better patient understanding of ACP are needed.

Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system

BACKGROUND

Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems.

METHODS

This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used.

RESULTS

From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment.

CONCLUSIONS

Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care. Cancer 2018;124:426-33. © 2017 American Cancer Society.

Prevalence and Clinical Intentions of Antithrombotic Therapy on Discharge to Hospice Care

BACKGROUND

There are no guidelines for antithrombotic therapy on admission to hospice care. Antithrombotic therapy may offer some benefit in these patients, but is also associated with well-described risks.

OBJECTIVE

We quantified the frequency and characteristics of patients prescribed antithrombotic therapy on discharge from acute care to hospice care.

DESIGN

Retrospective cohort study. Settings/Subjects: Adult (age> = 21 years) patients discharged from acute care to hospice care between January 1, 2010 and June 30, 2014.

MEASURES

Our primary outcome of interest was receiving an outpatient prescription for antithrombotic therapy on discharge to hospice care.

RESULTS

Among 1141 eligible patients, 77 (6.7%) patients received a prescription for antithrombotic therapy on discharge to hospice care, most frequently, aspirin (57.1%), enoxaparin (26.0%), and warfarin (20.8%). Patients actively treated for deep vein thromboembolism or pulmonary embolism, or with a history of atrial fibrillation or aortic/mitral valve replacement were significantly more likely to receive antithrombotic therapy. Patients with a history of cancer, cerebrovascular disease, or liver disease were significantly less likely to receive antithrombotic therapy (p < 0.05 for all). Among patients who received antithrombotic therapy, 22% were not receiving antithrombotic therapy before the index admission. Among patients previously receiving antithrombotic therapy, 55% continued on the same medication, of which 54.5% did not have any documented rationale for continuation.

CONCLUSIONS

Prescriptions for antithrombotic therapy were infrequent and often lacked a documented rationale. Further research is needed on the safety and effectiveness of antithrombotic therapy in hospice care and what drives current medication decisions in the absence of these data.

Chemotherapy in the ICU: Association between palliative care consultation and care goal documentation

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Background: Patients receiving chemotherapy in the intensive care unit (ICU) are at high risk of morbidity and mortality. A growing consensus supports proactively addressing goals of care (GOC) - prognosis, goals, fears, and treatment preferences - rather than waiting until treatment options are exhausted. Palliative care consultations frequently address GOC but most often occur late in cancer care. We hypothesized that palliative care consultation is associated with an increased likelihood of GOC documentation. Methods: We reviewed electronic medical records of all patients who received chemotherapy for a cancer diagnosis in OHSU ICUs from 2010-2015, collecting patient demographics, cancer diagnoses and comorbidities, timing of palliative care consultation, chemotherapy administration, GOC documentation, and survival at 30 and 180 days following ICU discharge. Survival and diagnosis were also checked against the OHSU Tumor Registry. Results: 214 patients met our inclusion criteria. Demographics reflect the Oregon population, but with a male predominance (64.5% male, N = 138). A majority of ICU patients receiving chemotherapy had a hematologic malignancy (80%, N = 172), and acute respiratory failure as the reason for ICU admission (42%, N = 90). The majority (84%, N = 179) survived their ICU stay and 67% (N = 143) survived 30 days post-ICU discharge, whereas 50% (N = 108) died by 180 days post-ICU discharge. Documentation of GOC discussions was found for 95 patients (44%) and was more likely in patients receiving palliative care consult (71/72 = 99%) compared to those who did not (24/142 = 17%), p < 0.0001, Fisher’s exact test. 63% of conversations occurred after chemotherapy had already been given (60.6% when palliative care was consulted, 70.8% when not, p = 0.4656). Conclusions: Chemotherapy in the ICU was associated with a 16% chance of dying in the ICU and a 50% 6 month mortality overall. Despite this, only 44% had documented GOC conversations and 63% of the conversations occurred after chemotherapy was initiated. Palliative care consultation was not associated with earlier GOC conversations. We recommend routine GOC conversations be initiated by oncologists prior to giving chemotherapy in the ICU setting.

The Oncology Specialist's Role in POLST Form Completion

INTRODUCTION

Patients with cancer and oncology professional societies believe that advance care planning is important, but we know little of who actually has this conversation. Physician Orders for Life-Sustaining Treatment (POLST) forms can help to document these important conversations to ensure patients receive the level of treatment they want. We therefore sought to determine the specialty of those signing POLST forms for patients who died of cancer to better understand who is having this discussion with patients.

METHODS

Retrospective cohort study including all deaths due to cancer in Oregon between January 1, 2010, and December 31, 2011. Death certificates were matched to POLST forms in the Oregon POLST Registry, and the signing physician's specialty was determined using the Oregon Medical Board's database.

RESULTS

A total of 14 979 people died of cancer in Oregon in 2010 to 2011. Of which, 6145 (41.0%) had at least 1 POLST form in the Registry. Oncology specialists signed 14.9% of POLST forms, compared to 53.7% by primary care, 15.3% by hospice/palliative care, 12.8% by advanced practice providers, and 2.7% by other specialists; 51.8% of oncology specialists did not sign a POLST form, whereas 12.5% completed 10 or more.

CONCLUSION

Oncology specialists play a central role in caring for patients with cancer through the end of their lives, but not in POLST completion. Whether or not they actually sign their patients' POLST forms, oncology specialists in the growing number of POLST states should integrate POLST into their goals of care conversations with patients nearing the end of life.

Antibiotic Policies and Utilization in Oregon Hospice Programs

Antibiotics are frequently used in hospice care, despite limited data on safety and effectiveness in this patient population. We surveyed Oregon hospice programs on antibiotic policies and prescribing practices. Among 39 responding hospice programs, the median reported proportion of current census using antibiotics was 10% (interquartile range = 3.5%-20.0%). Approximately 31% of responding hospice programs had policies for antibiotic initiation, 17% of hospice programs had policies for antibiotic discontinuation, and 95% of hospice programs had policies for managing drug interactions. Diarrhea, nausea/vomiting, and yeast infections were the most frequently reported antibiotic-associated adverse events, occurring “sometimes” or “often” among 62%, 47%, and 62% of respondents, respectively. In conclusion, less than a third of participating hospice programs reported having a policy for antibiotic initiation and even less frequently a policy for discontinuation. More data are needed on the risks and benefits of antibiotic use in hospice care to inform these policies and optimize outcomes in this vulnerable patient population.

Timing of POLST Form Completion by Cause of Death

CONTEXT

The physician orders for life-sustaining treatment (POLST) paradigm allows health care professionals to document the treatment preferences of patients with advanced illness or frailty as portable and actionable medical orders. National standards encourage offering POLST orders to patients for whom clinicians would not be surprised if they died in the next year.

OBJECTIVES

To determine the influence of cause of death on the timing of POLST form completion and on changes to POLST orders as death approaches.

METHODS

This was a cohort study of 18,285 Oregon POLST Registry decedents who died in 2010-2011 matched to Oregon death certificates.

RESULTS

The median interval between POLST completion and death was 6.4 weeks. Those dying of cancer had forms completed nearer death (median 5.1 weeks) than those with organ failure (10.6 weeks) or dementia (14.5 weeks; P < 0.001). More than 90% of final POLST forms indicated orders for no resuscitation and 65.1% listed orders for comfort measures only. Eleven percent of the sample had multiple registered forms during the two years preceding their death, with the form completed nearest to death more likely than earlier forms to have orders for no resuscitation and comfort measures only, although some later forms did have orders for more treatment.

CONCLUSION

More than half of POLST forms were completed in the final two months of life. Cause of death influenced when POLST forms were completed. POLST forms changed in the two years preceding death, more frequently recording fewer life-sustaining treatment orders than the earlier form(s).

Computerized patient-reported symptom assessment in radiotherapy: a pilot randomized, controlled trial

PURPOSE

Computer-based, patient-reported symptom survey tools have been described for patients undergoing chemotherapy. We hypothesized that patients undergoing radiotherapy might also benefit, so we developed a computer application to acquire symptom ratings from patients and generate summaries for use at point of care office visits and conducted a randomized, controlled pilot trial to test its feasibility.

METHODS

Subjects were randomized prior to beginning radiotherapy. Both control and intervention group subjects completed the computerized symptom assessment, but only for the intervention group were printed symptom summaries made available before each weekly office visit. Metrics compared included the Global Distress Index (GDI), concordance of patient-reported symptoms and symptoms discussed by the physician and numbers of new and/or adjusted symptom management medications prescribed.

RESULTS

One hundred twelve patients completed the study: 54 in the control and 58 in the intervention arms. There were no differences in GDI over time between the control and intervention groups. In the intervention group, more patient-reported symptoms were actually discussed in radiotherapy office visits: 46/202 vs. 19/230. A sensitivity analysis to account for within-subjects correlation yielded 23.2 vs. 10.3 % (p = 0.03). Medications were started or adjusted at 15.4 % (43/280) of control visits compared to 20.4 % (65/319) of intervention visits (p = 0.07).

CONCLUSIONS

This computer application is easy to use and makes extensive patient-reported outcome data available at the point of care. Although no differences were seen in symptom trajectory, patients who had printed symptom summaries had improved communication during office visits and a trend towards a more active symptom management during radiotherapy.

Life-sustaining treatment orders, location of death and co-morbid conditions in decedents with Parkinson's disease

INTRODUCTION

End-of-life care in Parkinson's Disease (PD) is poorly described. Physician Orders for Life Sustaining Treatment (POLST) forms specify how much life-sustaining treatment to provide. This study aims to better understand end-of-life care in PD using data from the Oregon POLST and Death Registries.

METHODS

Oregon death certificates from the years 2010-2011 were analyzed. Death certificates were matched with forms in the Oregon POLST Registry. Descriptive analyses were performed for both the full PD dataset as well as those with POLST forms.

RESULTS

There were 1073 (1.8%) decedents with PD listed as a cause of death and 56,961 without. Three hundred and seventy three (35%) decedents with PD had a POLST form. POLST preferences were not significantly different between those with or without PD, however location of death was; hospital (13% PD vs 24% without p < 0.01), home (32% vs 40% p < 0.01) and care facility (52% vs 29% p < 0.01). Compared to those without a POLST or those without a Comfort Measures Only (CMO) order, decedents with PD and a CMO order were less likely to die in a hospital (5.4% vs 14.7% p < 0.01) and more likely to die at home (39.1% vs 29.1% p < 0.01). In those with PD, dementia was the most common comorbid condition listed on death certificates (16%).

CONCLUSION

Decedents with PD die less frequently at home than the general population. POLST forms mitigate some of this discrepancy. While not often thought to be terminal, PD and its complications are commonly recorded causes of death.

A study to improve communication between clinicians and patients with advanced heart failure: methods and challenges behind the working to improve discussions about defibrillator management trial

We report the challenges of the Working to Improve Discussions About Defibrillator Management trial, our novel, multicenter trial aimed at improving communication between cardiology clinicians and their patients with advanced heart failure (HF) who have implantable cardioverter defibrillators (ICDs). The study objectives are (1) to increase ICD deactivation conversations, (2) to increase the number of ICDs deactivated, and (3) to improve psychological outcomes in bereaved caregivers. The unit of randomization is the hospital, the intervention is aimed at HF clinicians, and the patient and caregiver are the units of analysis. Three hospitals were randomized to usual care and three to intervention. The intervention consists of an interactive educational session, clinician reminders, and individualized feedback. We enroll patients with advanced HF and their caregivers, and then we regularly survey them to evaluate whether the intervention has improved communication between them and their HF providers. We encountered three implementation barriers. First, there were institutional review board concerns at two sites because of the palliative nature of the study. Second, we had difficulty in creating entry criteria that accurately identified an HF population at high risk of dying. Third, we had to adapt our entry criteria to the changing landscape of ventricular assist devices and cardiac transplant eligibility. Here we present our novel solutions to the difficulties we encountered. Our work has the ability to enhance conduct of future studies focusing on improving care for patients with advanced illness.

The role of patient pain and physical function on depressive symptoms in couples with lung cancer: a longitudinal dyadic analysis

Drawing on the Developmental-Contextual Model (Berg & Upchurch, 2007), we examined the association between changes in patient physical health (pain severity and physical function) and changes in depressive symptoms in couples with lung cancer over a 12-month period. Patients and their spouses or partners (n = 77) were recruited using rapid case ascertainment and completed five waves of data collection (baseline, 3, 6, 9, and 12 months). Multilevel modeling was used to examine aggregate and time-varying effects of patient physical health on depressive symptoms. Results indicated that for patients and spouses, patient-rated mean pain severity was significantly positively associated with patient and spouse depressive symptoms and patient-rated mean physical function was significantly negatively associated with patient and spouse depressive symptoms. More importantly, increases in patient pain severity and declines in patient physical function were significantly associated with increases in patient depressive symptoms. However, only declines in patient physical function were significantly associated with increases in spouse depressive symptoms. These time-varying effects remained even when controlling for patient gender, patient age, patient stage of disease, spouse physical health, and relationship quality. Findings suggest the importance of examining the changing illness context on the couple as a unit and the complexity of interpersonal processes in the presence of a life-threatening illness.

Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST Registry

BACKGROUND

Physician Orders for Life-Sustaining Treatment (POLST) has become a common means of documenting patient treatment preferences. In addition to orders either for Attempt Resuscitation or Do Not Attempt Resuscitation, for patients not in cardiopulmonary arrest, POLST provides three levels of treatment: Full Treatment, Limited Interventions, and Comfort Measures Only. Oregon has an electronic registry for POLST forms completed in the state. We used registry data to examine the different combinations of treatment orders.

METHODS AND RESULTS

We analyzed data from forms signed and entered into the Oregon POLST Registry in 2012. The analysis included 31,294 POLST forms. The mean Registrant age was 76.7 years. 21,396 (68.4%) had Do Not Attempt Resuscitation (DNR) orders and 9900 (31.6%) had orders for "Attempt Resuscitation". The 6 order combinations were: Do Not Resuscitate (DNR)/Comfort Measures Only 10,769 (34.4%), DNR/Limited Interventions 9306 (29.7%), DNR/Full Treatment 1211 (3.9%), Attempt Cardiopulmonary Resuscitation (CPR)/Comfort Measures Only 11 (0.04%), Attempt CPR/Limited Interventions 2281 (7.3%), and Attempt CPR/Full Treatment 7473 (23.9%).

CONCLUSIONS

The most common order combinations were DNR/Comfort Measures Only, DNR/Limited Interventions and Attempt Resuscitation/Full Treatment. These three makes sense to health professionals. However, other order combinations that require interpretation at the time of a crisis were completed for about 10% of Registrants. These combinations need further investigation.

Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review

BACKGROUND

Patients receiving hospice or palliative care often receive antimicrobial therapy; however the effectiveness of antimicrobial therapy for symptom management in these patients is unknown.

OBJECTIVE

The study's objective was to systematically review and summarize existing data on the prevalence and effectiveness of antimicrobial therapy to improve symptom burden among hospice or palliative care patients.

DESIGN

Systematic review of articles on microbial use in hospice and palliative care patients published from January 1, 2001 through June 30, 2011.

MEASUREMENTS

We extracted data on patients' underlying chronic condition and health care setting, study design, prevalence of antimicrobial use, whether symptom response following antimicrobial use was measured, and the method for measuring symptom response.

RESULTS

Eleven studies met our inclusion criteria in which prevalence of antimicrobial use ranged from 4% to 84%. Eight studies measured symptom response following antimicrobial therapy. Methods of symptom assessment were highly variable and ranged from clinical assessment from patients' charts to the Edmonton Symptom Assessment Scale. Symptom improvement varied by indication, and patients with urinary tract infections (two studies) appeared to experience the greatest improvement following antimicrobial therapy (range 67% to 92%).

CONCLUSION

Limited data are available on the use of antimicrobial therapy for symptom management among patients receiving palliative or hospice care. Future studies should systematically measure symptom response and control for important confounders to provide useful data to guide antimicrobial use in this population.