By Christopher Cheney
Nursing facilities that use Physician Orders for Life-Sustaining Treatment (POLST) forms achieve a higher level of concordance between orders in the medical record and resident preferences than facilities that do not use the forms, a recent study shows.
POLST forms are available across the country. Compared to living wills and durable power of attorney documents, POLST forms have been associated with significantly higher decreased odds of resuscitation attempts in the field and increased odds of out-of-hospital death for patients with “comfort measures only” directives.
The recent study, which was published by the Journal of General Internal Medicine, is based on information collected from 40 nursing facilities in Indiana. POLST was used in 29 of the nursing facilities and was not used in 11 facilities.
The research article includes two key findings:
- At nursing facilities using POLST, concordance between orders in the medical record and residents’ preferences was 59.3%. At nursing facilities that did not use POLST, concordance was 34.9%.
- When compared to nursing facility residents without POLST, residents with POLST were 3.05 times more likely to have orders for life-sustaining treatment match their current care preferences.
The lead author of the research article told HealthLeaders that POLST is a medical form that is used to document care preferences as orders, including orders about cardiopulmonary resuscitation, medical interventions, and artificial nutrition.
“The decisions that are most emergency-oriented are the orders for CPR and decisions around intubation, which is an intervention that is used when someone is having difficulty breathing and typically leads to the use of a ventilator. So, it is critical that preferences about those interventions be known in advance because there is rarely time in the moment to understand what a resident wants,” said Susan Hickman, PhD, director of the Indiana University Center for Aging Research at Regenstrief Institute in Indianapolis.
POLST is a valuable care tool because it can be followed by medical personnel both within a nursing facility and outside of the facility, she said. For example, a copy of a resident’s POLST form is usually included in the packet of materials that accompany a resident if he or she is taken to an acute care hospital.
“Emergency medical services play a crucial part in this process because they are a link between settings. So, if a resident starts to experience a medical emergency, EMS will be called to transport the resident to a hospital, and EMS is an important part of the process to make sure a resident’s preferences are honored. When the resident arrives at a hospital, the POLST orders are relevant in terms of making decisions about what care will be given in that setting,” Hickman said.
Nursing facilities use several strategies to ensure that POLST care preferences are honored, she said.
- Nursing facilities that use electronic medical records typically have code status on the face page of the medical record
- Code status is often communicated with a colored sticker on a resident’s door or chart in their room
- In addition to having a POLST form scanned into the medical record, some nursing facilities have a binder for every patient with a copy of the POLST form in it
In nursing facilities, POLST has taken on heightened importance during the coronavirus pandemic, Hickman said. “Nursing home residents and staff have been hard hit by COVID-19. For residents, this means that they are much more likely to imminently face decisions about hospitalization, ventilatory support, and cardiopulmonary resuscitation. Decisions that have been made previously may differ in the context of the pandemic.”
Rising to POLST challenges
The recent research article and earlier studies have found that two of the primary challenges of working with POLST in nursing facilities are staff difficulties with understanding and explaining the form as well as lack of time to have the POLST conversation.
These difficulties reflect both training gaps as well as advanced care planning often being an afterthought rather than being defined as part of staff members’ roles, Hickman said.
“Nursing home facilities and companies can address these difficulties by creating policies and procedures that support advanced care planning as well as recognizing that advanced care planning is part of staff members’ jobs. This may sound obvious, but it is often not. Advanced care planning is often added on without any clear responsibility or goals. There need to be policies for how often staff members talk about advanced care planning with residents and how staff members share what they learn,” she said.
Staff education and training is crucial, Hickman said. “Education needs to be provided on a regular basis—not just for the staff members holding the POLST conversations but also for everyone in the facility. Advanced care planning is a team sport—everyone has a role in honoring resident preferences.”
Additionally, nursing facilities routinely engage in quality improvement activities, and advanced care planning needs to become a focus of quality improvement initiatives on a regular basis, she said.
While acknowledging nursing facilities are “incredibly busy places,” Hickman said time spent managing POLST forms is time well spent.
“One of the things we here from staff is that when a facility invests the time upfront to have advanced care planning conversations, it helps save time and energy in the long run. Advanced care planning needs to be viewed as an investment, with the payout coming over time. It needs to be a priority—not just for individual staff members but also for the company or standalone facilities. There needs to be leadership engagement and buy-in,” she said.
Advanced care planning conversations
In healthcare settings, there are several skills that staff members should have to hold advanced care planning conversations, Hickman said.
“One important part of the skill set is knowledge about basic decisions that we are asking residents and surrogates to make. So, staff members need to understand the risks, benefits, and alternatives, and they need to be able to explain that information. Staff members need to know where there are resources to support the conversation. Additionally, it is critical for staff to have training to ask questions in value-neutral ways that help to understand the resident’s preferences rather than what the staff member’s preferences may be.”
Other skills include being able to ask questions that are open-ended to explore preferences and to help residents and family members to connect values to treatment, she said.
Christopher Cheney is the senior clinical care editor at HealthLeaders.