Care preferences in physician orders for life sustaining treatment in California nursing homes

Abstract

Background Physician Orders for Life‐Sustaining Treatment (POLST) facilitates documentation and transition of patients' life‐sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016. Methods California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross‐sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed‐effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five‐star quality rating. Results POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short‐stay:68%; long‐stay:81%). Among those with a POLST in 2016, 54% of long‐stay and 41% of short‐stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (<6%) had a POLST with contradictory orders. In regression analyses, POLST completion was greater among residents with more functional dependence, but was lower among those with more cognitive impairment. Greater functional and cognitive impairment were associated with DNR orders. Racial and ethnic minorities indicated more aggressive care preferences. Higher CMS five‐star facility quality rating was associated with greater POLST completion. Conclusions Six years after a state mandate to document POLST completion in NHs, most California NH residents have a POLST, and about half of long‐stay residents have orders to limit life‐sustaining treatment. Future work should focus on determining the quality of care preference decisions documented in POLST.

More POLST forms are being completed in nursing homes, but is this meaningful?

“…The completion of the POLST itself is not mandatory; documenting how it was completed is. In this issue of the Journal of the American Geriatrics Society , two articles by a team of researchers led by Jennings and Zingmond leverage the data produced by this mandate to examine how care preferences in NH patients are being documented in California and how that has changed over time 1,2 …”

“…In this issue of the Journal of the American Geriatrics Society, two articles by a team of researchers led by Jennings and Zingmond leverage the data produced by this mandate to examine how care preferences in NH patients are being documented in California and how that has changed over time. 1,2 Jennings et al reported three major findings. First, POLST completion rose in the 5 years following the mandate.…”

“…At our California nursing home, Physician Orders for Life-Sustain Treatment (or POLST) are printed off on bright ultra-pink POLST forms that sit prominently at the front of patients' charts. They are pre-filled by the admitting nurse who checks off boxes indicating (1) whether facility staff should attempt cardiopulmonary resuscitation (CPR) or not (do not resuscitate, or DNR), (2) whether patients should receive full, selective or comfort-focused treatment, (3) conditions for transfer to hospital, and (4) whether artificial nutrition should be administered (see Figure 1). Forms are signed by patients or their representative and, after verifying their preferences and amending the form if necessary, we as physicians sign them.…”

Changes over time in POLST use and content by race and ethnicity among California nursing home residents

“…11 But, fewer Black and Hispanic nursing home residents, compared to White residents, have POLST forms containing DNR orders. 12 Previous research concerning DNR orders in the inpatient setting suggests that racial and ethnic differences have not changed over time. 13,14 However, there is increasing interest in understanding variation in medical decision-making by race and ethnicity.…”

“…POLST—which requires formulation of resuscitation preference and other care preferences and ideally occurs before hospitalization—appears to be employed to about the same degree among White, Black, and Hispanic nursing home residents 11 . But, fewer Black and Hispanic nursing home residents, compared to White residents, have POLST forms containing DNR orders 12 . Previous research concerning DNR orders in the inpatient setting suggests that racial and ethnic differences have not changed over time 13,14 .…”