Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities

Abstract

Background Individuals with heart failure (HF) who are hospitalized and admitted to skilled nursing facilities (SNFs) are at high risk for rehospitalization and death. The care preferences of this high-risk population have not been studied. Objectives To describe care preferences of patients with HF admitted to SNFs for rehabilitation based on Medical Orders for Scope of Treatment (MOST) documentation, and evaluate goal-concordant care based on MOST documentation, emergency department (ED) visits, and hospitalization. Design, setting, and participants Retrospective study of patients with HF in 35 SNFs enrolled in a randomized controlled trial of HF-disease management versus usual care between July 2014 and May 2016. Measurements Validity of MOST forms, care preference documentation, and ED visits/hospitalizations within 60 days of SNF admission. Results Of 370 patients (mean age 78.6 years, 58% women, 25% systolic HF), 278 (75%) had a MOST form in the SNF chart, of which 96 forms (35%) were invalid. The most common reason for an invalid MOST form was missing date accompanying patient or provider signature. Of 182 valid MOST forms, 47% of patients chose no cardiopulmonary resuscitation (“No CPR”), 58% selected “Full Treatment,” 17% chose “Selective Treatment,” and 23% chose “Comfort-Focused Treatment.” Patients who were older [odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.25, 1.81] and female (OR = 2.33, 95% CI = 1.18, 4.59) had higher odds of choosing “No CPR.” Sixty-six of 182 patients (36%) with valid MOST forms had an ED/hospital visit within 60 days of SNF admission; only 3 patients received medical care that was potentially discordant: all 3 chose “Comfort-Focused Treatment” and were hospitalized for more than symptom management. Conclusion Seventy-five percent of patients with HF admitted to SNFs had care preferences documented using the MOST form, and 95% received goal-concordant care based on care preferences documented during the SNF admission. Clinicaltrials.gov # NCT01822912.

Are We Getting What We Really Want? A Systematic Review of Concordance Between Physician Orders for Life-Sustaining Treatment (POLST) Documentation and Subsequent Care Delivered at End-of-Life

“…17 While most study designs were retrospective cohort studies, [11][12][13][14][16][17][18][19][20][21] Tolle's study was the only prospective study that collected data in real time and conducted chart reviews. 15 The combined study sample size was 5,688 individuals who documented EoL care wishes on POLST forms, recruited from a various care settings; nursing homes, 12,14,15,17 elderly care facilities, 16 community settings, 11,[18][19][20] and academic hospitals. 13 Majority of study samples were White (78.8%), female (54.3%), with mean age of 79.8 years.…”

“…Specifically, 3 ("advance care planning"/exp OR "advance care planning") AND ("living will"/exp OR "living will") OR "care discussion" OR "end of life" OR "end of life care discussion" OR "care planning" OR "end of life care planning" OR "eol care planning" 175,307 2 "terminal care" OR "palliative therapy" OR "palliative nursing" OR "hospice nursing" OR "hospice" OR "end of life" 165,056 3 1AND2 40,075 4 "POLST" OR "MOLST" OR "COLST" OR "portable orders for life sustaining treatment" OR "physician orders for life sustaining treatment" OR "medical orders for life-sustaining treatment" OR "summary of physician orders for scope of treatment" OR "clinician orders for life sustaining treatment" OR "clinical orders for life sustaining treatment" OR "physician orders for scope of treatment" studies compared the preferred level of care (e.g., comfort only vs. limited vs. full treatment) indicated on POLST forms and whether wishes were respected. 13,16,17 Four studies examined the POLST wishes for hospitalization, 12,14,15,18 and 3 studies examined the POLST wishes for the receipt of care in an ICU setting. 15,16,18 Overall, preferred level of medical interventions showed concordance of 68.5% (range: 46%-91.1%), and the wishes to avoid/ transfer to hospital or ICU settings were concordant wish documented wishes 94% of the time (median 95.5%, range 85-100%).…”

“They Need to Have an Understanding of Why They're Coming Here and What the Outcomes Might Be.” Clinician Perspectives on Goals of Care for Patients Discharged From Hospitals to Skilled Nursing Facilities

“…The use of POLST forms show promise, with recent evidence indicating that SNF residents with POLST forms in place receive goal-concordant care. 30,31 The recent interest in identifying causes of hospital readmissions from SNFs is not surprising, given the financial penalties hospitals pay and the new penalties SNFs will soon pay because of excessive patient readmissions. 6 Beyond financial consequences, hospital readmissions from SNFs are costly for the patient, often leading to in-hospital complications and high rates of patient mortality.…”

POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care

“…8 These findings highlight program and policy issues with POLST use in nursing homes and are consistent with a series of studies that have identified issues with nursing home use, including staff difficulty understanding and explaining the form, discomfort with issues raised by the form, and problems using the form to guide treatment. 4,9 One specific problematic practice that contributes to these difficulties is use of POLST as a universal code status order form to document CPR orders. In a recent National POLST survey of state POLST programs, almost half of program representatives who responded to the survey (15 of 33 or 45.4%) reported that POLST is at least sometimes used as a code status order form in their state and 9 (60%) of 15 who reported this occurs describe the practice as "very widespread" or "common" in their state (Vandenbroucke A.…”