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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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Shayya A, Young Y. End-of-Life Medical Decisions: The Link Between Sociodemographic Characteristics and Treatment Preferences. Am J Hosp Palliat Care 2023:10499091231218988. [PMID: 38008990 DOI: 10.1177/10499091231218988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
INTRODUCTION Advance directives (ADs) promote patient autonomy in end-of-life (EOL) care, including an individual's EOL medical treatment preferences. This study aims to better understand preferences regarding EOL medical treatment among community-dwelling adults (18 and older) residing in the United States and examine the association between sociodemographic characteristics and EOL medical treatment preferences. METHODS Utilizing a cross-sectional study and snowball sampling methodology, community-dwelling adults completed a survey containing two different ADs and a questionnaire with sociodemographic information. Univariate analyses were used to summarize EOL medical treatment preferences among the sample, and bivariate analyses (Chi-square and Fisher's Exact tests) were performed to examine the association between sociodemographic characteristics (age, gender, and race/ethnicity) and EOL medical treatment preferences. RESULTS The mean age of the 166 participants was 50 (SD: 21.65, range: 18-93), with 58.4% being White and 61.4% being female. Generally, when EOL scenarios involved brain damage or a coma, more participants indicated that they did not want life-support treatment. Age and race were both associated with EOL medical treatment preferences, but no significant differences were observed in the bivariate results by gender. Largely, young and middle-aged adults, along with Black participants, were more likely to prefer more aggressive EOL medical treatments than older adults and White participants. CONCLUSION Overall, EOL medical treatment preferences varied among participants. The study findings indicate that adults develop different preferences for EOL medical treatment, with some of the variation attributable to sociodemographic characteristics such as age and race.
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Affiliation(s)
- Ashley Shayya
- Department of Health Policy, Management, and Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Yuchi Young
- Department of Health Policy, Management, and Behavior, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
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Keller MS, Mavilian C, Altom KL, Erickson KF, Drudi LM, Woo K. Barriers to Implementing the Kidney Disease Outcomes Quality Initiative End-Stage Kidney Disease Life Plan Guideline. J Gen Intern Med 2023; 38:3198-3208. [PMID: 37407766 PMCID: PMC10651571 DOI: 10.1007/s11606-023-08290-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The updated 2019 National Kidney Foundation Kidney Disease Outcomes Quality Initiative vascular access guidelines recommend patient-centered, multi-disciplinary construction and regular update of an individualized end-stage kidney disease (ESKD) Life-Plan (LP) for each patient, a dramatic shift from previous recommendations and policy. The objective of this study was to examine barriers and facilitators to implementing the LP among key stakeholders. METHODS Semi-structured individual interviews were analyzed using inductive and deductive coding. Codes were mapped to relevant domains in the Consolidated Framework for Implementation Research (CFIR). RESULTS We interviewed 34 participants: 11 patients with end-stage kidney disease, 2 care partners, and 21 clinicians who care for patients with end-stage kidney disease. In both the clinician and the patient/care partner categories, saturation (where no new themes were identified) was reached at 8 participants. We identified significant barriers and facilitators to implementation of the ESKD LP across three CFIR domains: Innovation, Outer setting, and Inner setting. Regarding the Innovation domain, patients and care partners valued the concept of shared decision-making with their care team (CFIR construct: innovation design). However, both clinicians and patients had significant concerns about the complexity of decision-making around kidney substitutes and the ability of patients to digest the overwhelming amount of information needed to effectively participate in creating the LP (innovation complexity). Clinicians expressed concerns regarding the lack of existing evidence base which limits their ability to effectively counsel patients (innovation evidence base) and the implementation costs (innovation cost). Within the Outer Setting, both clinicians and patients were concerned about performance measurement pressure under the existing "Fistula First" policies and had concerns about reimbursement (financing). In the Inner Setting, clinicians and patients stressed the lack of available resources and access to knowledge and information. CONCLUSION Given the complexity of decision-making around kidney substitutes and vascular access, our findings point to the need for implementation strategies, infrastructure development, and policy change to facilitate ESKD LP development.
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Affiliation(s)
- Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Christine Mavilian
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Keaton L Altom
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | - Kevin F Erickson
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Laura M Drudi
- Division of Vascular Surgery, Centre Hospitalier de L'Université de Montréal (CHUM), Montreal, QC, Canada
- Innovation Hub, Centre de Recherche du CHUM, Montreal, QC, Canada
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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Disclosure of Medical Errors. Ann Emerg Med 2023; 82:e81-e85. [PMID: 37479417 DOI: 10.1016/j.annemergmed.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 07/23/2023]
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Patient-physician conversations about life-sustaining treatment: Treatment preferences and participant assessments. Palliat Support Care 2023; 21:20-26. [PMID: 36814149 DOI: 10.1017/s1478951521001875] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients' treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form. METHODS The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making. RESULTS A total of 95 patients (aged 41-95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree. SIGNIFICANCE OF RESULTS The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.
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Wang DH, Breyre AM, Brooten JK, Hanson KC. Top Ten Tips Palliative Care Clinicians Should Know About Improving Partnerships with Emergency Medical Services. J Palliat Med 2023; 26:704-710. [PMID: 36607791 DOI: 10.1089/jpm.2022.0537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Emergency medical services (EMS) clinicians increasingly encounter seriously ill patients and their caregivers in times of distress. When crises arise or care coordination falls short, these high-stakes interactions highlight opportunities to improve care experience and outcomes. Efforts must address wide educational gaps, absence of specialized care protocols, and systematic fragmentation leading to hyperlocal practice. The authors represent cross-sectional expertise in palliative care and EMS. This article describes unmet needs at the EMS-palliative interface, challenges with collaboration, and where directional progress exists.
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Affiliation(s)
- David H Wang
- Department of Palliative Medicine, Scripps Health, San Diego, California, USA
| | - Amelia M Breyre
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Justin K Brooten
- Department of Emergency Medicine and Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.,Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kenneth C Hanson
- Department of Emergency Medicine, Central Michigan University College of Medicine-East Campus, Saginaw, Michigan, USA
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Jennings LA, Wenger NS, Liang LJ, Parikh P, Powell D, Escarce JJ, Zingmond D. Care preferences in physician orders for life sustaining treatment in California nursing homes. J Am Geriatr Soc 2022; 70:2040-2050. [PMID: 35275398 DOI: 10.1111/jgs.17737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/02/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
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.
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Affiliation(s)
- Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - David Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Zingmond DS, Powell D, Jennings LA, Escarce JJ, Liang LJ, Parikh P, Wenger NS. POLST completion and continuity in California nursing homes. J Am Geriatr Soc 2021; 70:2148-2150. [PMID: 34927721 DOI: 10.1111/jgs.17610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- David S Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Breyre AM, Benesch T, Glomb NW, Sporer KA, Anderson WG. EMS Experience Caring and Communicating with Patients and Families with a Life-Limiting-Illness. PREHOSP EMERG CARE 2021; 26:708-715. [PMID: 34669550 DOI: 10.1080/10903127.2021.1994674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The emergency medical services (EMS) system was designed to reduce death and disability and EMS training focuses on saving lives through resuscitation, aggressive treatment and transportation to the emergency department. EMS providers commonly care for patients who have life-limiting illnesses. The objective was to explore EMS provider challenges, self-perceived roles and training experiences caring for patients and families with life-limiting illness. Methods: Qualitative content analysis of semi-structured interviews with EMS providers (n = 15) in Alameda County, CA. Purposive sampling was used to ensure a variety of perspectives including provider age, years of EMS experience, emergency medical technicians and paramedics, fire-based versus private, transport versus non-transporting. Recorded and transcribed interviews were analyzed using a thematic approach. Results: In their work with patients with life-limiting illness, participating EMS providers were interviewed and reported challenges for which their formal training had not prepared them: responding to grief and emotion expressed by families during traumatic events or death notification, and performing in the moment decision-making to determine the course of action after acute, unexpected, and traumatic events. Many participants reported becoming comfortable with grief counseling and death notification after acquiring some clinical experience. In the moment decision-making was eased when patients and families had had advance care planning discussions, however many patients, especially those from vulnerable and underserved populations, lacked advance care planning. In the face of situations where the course of action was not immediately clear, EMS providers voiced two frames for their role in caring for patients with life-limiting illness: transportation only ("transport people") versus a more "holistic" view, where EMS providers provided counseling and information about available resources. Conclusions: EMS providers interface with patients who have life-limiting illness and their families in the setting of traumatic events where the course of action is often unclear. There is an opportunity to provide formal training to EMS providers around grief counseling as well as how they can assist patients and families in in the moment decision-making to support previously identified goals and align care with patient goals and preferences.
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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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Lin AL, Newgard C, Caughey AB, Malveau S, Dotson A, Eckstrom E. End-of-Life Orders, Resource Utilization, and Costs Among Injured Older Adults Requiring Emergency Services. J Gerontol A Biol Sci Med Sci 2021; 76:1686-1691. [PMID: 32914190 DOI: 10.1093/gerona/glaa230] [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] [Received: 05/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Portable Orders for Life-Sustaining Treatment (POLST) are increasingly utilized to assist patients approaching the end of life in documenting goals of care. We evaluated the association of POLST, resource utilization, and costs to 1 year among injured older adults requiring emergency services. METHODS This was a retrospective cohort of injured older adults ≥65 years with continuous Medicare fee-for-service coverage transported by emergency medical services (EMS) in 2011 across 4 counties in Oregon. Data sources included EMS, Medicare claims, vital statistics, and state POLST, inpatient and trauma registries. Outcomes included hospital admission, receipt of aggressive medical interventions, costs, and hospice use. We matched patients on patient characteristics and comorbidities to control for bias. RESULTS We included 2116 patients of which 484 (22.9%) had a POLST form prior to 911 contact. Of POLST patients, 136 (28.1%) had orders for full treatment, 194 (40.1%) for limited interventions, and 154 (31.8%) for comfort measures. There were no significant associations for care during the index event. However, in the year after the index event, patients with care limitations had higher adjusted hospice use (limited interventions OR 1.7 [95% CI: 1.2-2.6]; comfort OR, 2.0 [95% CI: 1.3-3.0]) and lower adjusted post-discharge costs (no POLST, $32,399 [95% CI: 30,041-34,756]; limited interventions, $18,729 [95% CI: 12,913-24,545]; and comfort $15,593 [95% CI: 12,091-19,095]). There were no significant associations for all other outcomes. CONCLUSIONS Care limitations specified in POLST forms among injured older adults transported by EMS are associated with increased use of hospice and decreased costs to 1 year.
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Affiliation(s)
- Amber L Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Abby Dotson
- Oregon POLST Registry, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Elizabeth Eckstrom
- Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland
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Chung YJ, Park I, Cho J, Beom JH, Lee JE. Consent for withholding life-sustaining treatment in cancer patients: a retrospective comparative analysis before and after the enforcement of the Life Extension Medical Decision law. BMC Med Ethics 2021; 22:72. [PMID: 34140017 PMCID: PMC8210737 DOI: 10.1186/s12910-021-00644-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background The Life Extension Medical Decision law enacted on February 4, 2018 in South Korea was the first to consider the suspension of futile life-sustaining treatment, and its enactment caused a big controversy in Korean society. However, no study has evaluated whether the actual implementation of life-sustaining treatment has decreased after the enforcement of this law. This study aimed to compare the provision of patient consent before and after the enforcement of this law among cancer patients who visited a tertiary university hospital's emergency room to understand the effects of this law on the clinical care of cancer patients. Methods This retrospective single cohort study included advanced cancer patients aged over 19 years who visited the emergency room of a tertiary university hospital. The two study periods were as follows: from February 2017 to January 2018 (before) and from May 2018 to April 2019 (after). The primary outcome was the length of hospital stay. The consent rates to perform cardiopulmonary resuscitation (CPR), intubation, continuous renal replacement therapy (CRRT), and intensive care unit (ICU) admission were the secondary outcomes. Results The length of hospital stay decreased after the law was enforced from 4 to 2 days (p = 0.001). The rates of direct transfers to secondary hospitals and nursing hospitals increased from 8.2 to 21.2% (p = 0.001) and from 1.0 to 9.7%, respectively (p < 0.001). The consent rate for admission to the ICU decreased from 6.7 to 2.3% (p = 0.032). For CPR and CRRT, the consent rates decreased from 1.0 to 0.0% and from 13.9 to 8.8%, respectively, but the differences were not significant (p = 0.226 and p = 0.109, respectively). Conclusion After the enforcement of the Life Extension Medical Decision law, the length of stay in the tertiary university hospital decreased in patients who established their life-sustaining treatment plans in the emergency room. Moreover, the rate of consent for ICU admission decreased.
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Affiliation(s)
- Yu Jin Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu 120-752, Seoul, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu 120-752, Seoul, Republic of Korea
| | - Junho Cho
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu 120-752, Seoul, Republic of Korea
| | - Jin Ho Beom
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu 120-752, Seoul, Republic of Korea.
| | - Ji Eun Lee
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu 120-752, Seoul, Republic of Korea
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Bible KC, Kebebew E, Brierley J, Brito JP, Cabanillas ME, Clark TJ, Di Cristofano A, Foote R, Giordano T, Kasperbauer J, Newbold K, Nikiforov YE, Randolph G, Rosenthal MS, Sawka AM, Shah M, Shaha A, Smallridge R, Wong-Clark CK. 2021 American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer. Thyroid 2021; 31:337-386. [PMID: 33728999 PMCID: PMC8349723 DOI: 10.1089/thy.2020.0944] [Citation(s) in RCA: 270] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Since the guidelines for the management of ATC by the American Thyroid Association were first published in 2012, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, and researchers on published evidence relating to the diagnosis and management of ATC. Methods: The specific clinical questions and topics addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of the Task Force members (authors of the guideline). Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. Results: The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, targeted/systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues, including end of life. The guidelines include 31 recommendations and 16 good practice statements. Conclusions: We have developed evidence-based recommendations to inform clinical decision-making in the management of ATC. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with ATC.
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Affiliation(s)
- Keith C. Bible
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Electron Kebebew
- Stanford University, School of Medicine, Stanford, California, USA
| | - James Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Juan P. Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria E. Cabanillas
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Antonio Di Cristofano
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert Foote
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Thomas Giordano
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jan Kasperbauer
- Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kate Newbold
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, United Kingdom
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - M. Sara Rosenthal
- Program for Bioethics and Markey Cancer Center Oncology Ethics Program, Departments Internal Medicine, Pediatrics and Behavioral Science, University of Kentucky, Lexington, Kentucky, USA
| | - Anna M. Sawka
- Division of Endocrinology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Manisha Shah
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashok Shaha
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Mirarchi F, Juhasz K, Cooney T, Desiderio D. TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end-of-life-The Realistic Interpretation of Advance Directives. J Healthc Risk Manag 2020; 41:22-30. [PMID: 33301646 DOI: 10.1002/jhrm.21453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Utilize simulation to evaluate if living wills (LW) or POLST achieves goal concordant Care (GCC) in a medical crisis. METHODS Nurses and resident-physicians from a single center were randomized to a clinical scenario with a living will (LW), physician orders for life sustaining treatment (POLST) or no document. Primary outcomes were resuscitation decision and time to decision. Secondary outcome was the effect of education. RESULTS Total enrollment was 57 and less than 30% received prior training. Types of directives were linked to resuscitation decisions (P = .019). Participants randomized to "No Document" or POLST specifying "CPR" performed resuscitation. If a terminal condition presented with a POLST/ do not resuscitate-comfort measures only (DNR-CMO), 73% resuscitated. The LW or POLST specifying DNR combined with medical support resulted in resuscitations in 29% or more of the scenarios. Documents did not significantly affect median time-to-decision (P = .402) but decisions for "No Document" and POLST/CPR were at least 10 s less than other scenarios. Scenarios involving POLST DNR/Limited Treatment had the highest median time of 43 s. Prior training in LWs and POLST exerted a 10% improvement in decision making (P = .537). CONCLUSION GCC was not always achieved with a LW or POLST. This conclusion supports prior research identifying problems with the interpretation and discordance with LW's and POLST.
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Affiliation(s)
| | - Kristin Juhasz
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Timothy Cooney
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Daniel Desiderio
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
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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 PMCID: PMC7744421 DOI: 10.1111/jgs.16828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Matthew E. Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Counts CR, Blackwood J, Winchell R, Drucker C, Jennerich AL, Feder S, Pompeo K, Waldron J, Sayre MR, Kudenchuk PJ, Rea T. Emergency Medical Services and Do Not Attempt Resuscitation directives among patients with out-of-hospital cardiac arrest. Resuscitation 2020; 158:73-78. [PMID: 33221365 DOI: 10.1016/j.resuscitation.2020.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/17/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Emergency Medical Services (EMS) are often involved in end-of-life circumstances, yet little is known about how EMS interfaces with advance directives to forego unwanted resuscitation (Do Not Attempt Resuscitation (DNAR)). We evaluated the frequency of these directives involved in out-of-hospital cardiac arrest (OHCA) and how they impact care. METHODS We conducted a cohort investigation of adult, EMS-attended OHCA from January 1 to December 31, 2018 in King County, WA. DNAR status was ascertained from dispatch, EMS, and hospital records. Resuscitation was classified according to DNAR status: not initiated, initiated but ceased due to the DNAR, or full efforts. RESULTS Of 3152 EMS-attended OHCA, 314 (9.9%) had a DNAR directive. DNAR was present more often among those for whom EMS did not attempt resuscitation compared to when EMS provided some resuscitation (13.2% [212/1611] vs 6.6% [101/1541], (p < 0.05). Of those receiving resuscitation with a DNAR directive (n = 101), the DNAR was presented on average 6 min following EMS arrival. A total of 82% (n = 83) had EMS efforts ceased as a consequence of the DNAR while 18% (n = 18) received full efforts. Full-efforts compared to ceased-efforts were more likely to have a witnessed arrest (67% vs 36%), present with shockable rhythm (22% vs 6%), achieve spontaneous circulation by time of DNAR presentation (50% vs 4%), and have family contradict the DNAR (33% vs 0%) (p < 0.05 for each comparison). CONCLUSIONS Approximately 10% of EMS-attended OHCA involved DNAR. EMS typically fulfilled this end-of-life preference, though wishes were challenged by delayed directive presentation or contradictory family wishes.
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Affiliation(s)
- Catherine R Counts
- Department of Emergency Medicine, University of Washington, United States; Seattle Fire Department, United States.
| | - Jennifer Blackwood
- Emergency Medical Services Division of Public Health - Seattle & King County, United States
| | - Ryan Winchell
- University of Washington School of Medicine, United States
| | - Christopher Drucker
- Emergency Medical Services Division of Public Health - Seattle & King County, United States
| | - Ann L Jennerich
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, United States
| | | | | | - Jody Waldron
- Department of Medicine, Division of General Medicine, University of Washington, United States
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, United States; Seattle Fire Department, United States
| | - Peter J Kudenchuk
- Emergency Medical Services Division of Public Health - Seattle & King County, United States; Department of Medicine, Division of Cardiology, University of Washington, United States
| | - Thomas Rea
- Emergency Medical Services Division of Public Health - Seattle & King County, United States; Department of Medicine, Division of General Medicine, University of Washington, United States
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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Myall M, May C, Richardson A, Bogle S, Campling N, Dace S, Lund S. Creating pre-conditions for change in clinical practice: the influence of interactions between multiple contexts and human agency. J Health Organ Manag 2020; ahead-of-print. [PMID: 33103399 PMCID: PMC9251639 DOI: 10.1108/jhom-06-2020-0240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to explore what happens when changes to clinical practice are proposed and introduced in healthcare organisations. The authors use the implementation of Treatment Escalation Plans to explore the dynamics shaping the translational journey of a complex intervention from research into the everyday context of real-world healthcare settings.Design/methodology/approachA qualitative instrumental collective case study design was used. Data were gathered using qualitative interviews (n = 36) and observations (n = 46) in three English acute hospital trusts. Normalisation process theory provided the theoretical lens and informed data collection and analysis.FindingsWhile each organisation faced the same translational problem, there was variation between settings regarding adoption and implementation. Successful change was dependent on participants' ability to manage and shape contexts and the work this involved was reliant on individual capacity to create a new, receptive context for change. Managing contexts to facilitate the move from research into clinical practice was a complex interactive and iterative process.Practical implicationsThe paper advocates a move away from contextual factors influencing change and adoption, to contextual patterns and processes that accommodate different elements of whole systems and the work required to manage and shape them.Originality/valueThe paper addresses important and timely issues of change in healthcare, particularly for new regulatory and service-oriented processes and practices. Insights and explanations of variations in implementation are revealed which could contribute to conceptual generalisation of context and implementation.
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Affiliation(s)
- Michelle Myall
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Carl May
- Faculty of Public Health and Policy,
London School of Hygiene and Tropical Medicine
, London,
UK
| | - Alison Richardson
- School of Health Sciences,
University of Southampton
, Southampton,
UK
- Clinical Academic Facility, Southampton General Hospital,
University Hospital Southampton NHS Foundation Trust
, Southampton,
UK
| | - Sarah Bogle
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Natasha Campling
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Sally Dace
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Susi Lund
- School of Health Sciences,
University of Southampton
, Southampton,
UK
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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: 27] [Impact Index Per Article: 6.8] [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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20
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The impact of language on the interpretation of resuscitation clinical care plans by doctors. A mixed methods study. PLoS One 2019; 14:e0225338. [PMID: 31765418 PMCID: PMC6876871 DOI: 10.1371/journal.pone.0225338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/01/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Resuscitation clinical care plans (resuscitation plans) are gradually replacing ‘Not for Cardiopulmonary Resuscitation’ orders in the hospital setting. The 7-Step Pathway Resuscitation Plan and Alert form (7-Step form) is one example of a resuscitation plan. Treatment recommendations in resuscitation plans currently lack standardised language, creating potential for misinterpretation and patient harm. Aims To explore how terminology used in resuscitation plans is interpreted and applied by clinicians. Method A mixed methods study surveyed 50 general medical doctors, who were required to interpret and apply a 7-Step form in three case vignettes and define seven key terms. Statistical analysis on multiple choice and thematic analysis on free-text responses was performed. Results Terminology was inconsistently interpreted and inconsistently applied, resulting in clinically significant differences in treatment choices. Three key themes influenced the application of a resuscitation plan: in-depth discussion, precise documentation and personal experience of the bedside deciding doctor. Discussion This study highlights persistent communication deficiencies in resuscitation plan documentation and how this may adversely affect patient care; findings unlikely to be unique to Australia or South Australia. Conclusion Removing ambiguity by standardising and defining the terminology in resuscitation plans will improve bedside decision-making, while also supporting the rights of the patient to receive appropriate and desired care.
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Buiar PG, Goldim JR. Barriers to the composition and implementation of advance directives in oncology: a literature review. Ecancermedicalscience 2019; 13:974. [PMID: 31921345 PMCID: PMC6946425 DOI: 10.3332/ecancer.2019.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 12/21/2022] Open
Abstract
The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.
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Affiliation(s)
- Pedro Grachinski Buiar
- Medical Oncology Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0001-5144-1197
| | - José Roberto Goldim
- Bioethics Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0003-2127-6594
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Chen EE, Pu CT, Bernacki RE, Ragland J, Schwartz JH, Mutchler JE. Surrogate Preferences on the Physician Orders for Life-Sustaining Treatment Form. THE GERONTOLOGIST 2019; 59:811-821. [PMID: 29788197 DOI: 10.1093/geront/gny042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study is to compare treatment preferences of patients to those of surrogates on the Physician Orders for Life-Sustaining Treatment (POLST) forms. RESEARCH DESIGN AND METHODS Data were collected from a sequential selection of 606 Massachusetts POLST (MOLST) forms at 3 hospitals, and corresponding electronic patient health records. Selections on the MOLST forms were categorized into All versus Limit Life-Sustaining Treatment. Multivariable mixed effects (grouped by clinician) logistic regression models estimated the impact of using a surrogate decision maker on choosing All Treatment, controlling for patient characteristics (age, severity of illness, sex, race/ethnicity), clinician (physician vs non-physician), and hospital (site). RESULTS Surrogates signed 253 of the MOLSTs (43%). A multivariable logistic regression model taking into consideration patient, clinician, and site variables showed that surrogate decision makers were 60% less likely to choose All Treatment than patients who made their own decisions (odds ratio = 0.39 [95% confidence interval = 0.24-0.65]; p < .001). This model explained 44% of the variation in the dependent variable (Pseudo-R2 = 0.442; p < .001); mixed effects logistic regression grouped by clinician showed no difference between the models (LR test = 4.0e-13; p = 1.00). DISCUSSION AND IMPLICATIONS Our study took into consideration variation at the patient, clinician, and site level, and showed that surrogates had a propensity to limit life-sustaining treatment. Surrogate decision makers are frequently needed for hospitalized patients, and nearly all states have adopted the POLST. Researchers may want study decision-making processes for patients versus surrogates when the POLST paradigm is employed.
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Affiliation(s)
| | | | - Rachelle E Bernacki
- Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Jan E Mutchler
- Gerontology Department and Institute, University of Massachusetts Boston
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Tark A, Agarwal M, Dick AW, Stone PW. Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan. J Palliat Med 2019; 22:1032-1038. [PMID: 30789297 PMCID: PMC6735313 DOI: 10.1089/jpm.2018.0626] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.
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Affiliation(s)
- Aluem Tark
- Center for Health Policy and Center for Improving Palliative Care for Vulnerable Adults with Multiple Chronic Conditions, Columbia University School of Nursing, New York, New York
| | - Mansi Agarwal
- Center for Health Policy and Center for Improving Palliative Care for Vulnerable Adults with Multiple Chronic Conditions, Columbia University School of Nursing, New York, New York
| | | | - Patricia W. Stone
- Center for Health Policy and Center for Improving Palliative Care for Vulnerable Adults with Multiple Chronic Conditions, Columbia University School of Nursing, New York, New York
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Zive D, Newgard CD, Lin A, Caughey AB, Malveau S, Eckstrom E. Injured Older Adults Transported by Emergency Medical Services: One Year Outcomes by POLST Status. PREHOSP EMERG CARE 2019; 24:257-264. [PMID: 31058558 DOI: 10.1080/10903127.2019.1615154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. We linked multiple data sources to EMS records, including: the Oregon POLST Registry, Medicare claims data, Oregon Trauma Registry, Oregon statewide inpatient data, and Oregon vital statistics records. We describe patient and event characteristics by POLST status at time of 9-1-1 contact, subsequent changes in POLST forms, and mortality to 12 months. Results: Of 7,055 injured older adults, 1,412 (20.0%) had a registered POLST form at the time of 911 contact. Among the 1,412 POLST forms, 390 (27.6%) specified full orders, 585 (41.4%) limited interventions, and 437 (30.9%) comfort measures only. By one year, 2,471 (35%) patients had completed POLST forms. Among the 4 groups (no POLST, POLST-full orders, POLST-limited intervention, POLST-comfort measures), Injury Severity Scores were similar. Mortality differences were present by 30 days (5.0%, 4.6%, 8.0%, and 13.3%, p < 0.01) and were greater by one year (19.5%, 23.9%, 35.4%, and 46.2%, p < 0.01). Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up.
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Starr LT, Ulrich CM, Corey KL, Meghani SH. Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review. Am J Hosp Palliat Care 2019; 36:913-926. [PMID: 31072109 DOI: 10.1177/1049909119848148] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Aggressive end-of-life (EOL) care is associated with lower quality of life and greater regret about treatment decisions. Higher EOL costs are also associated with lower quality EOL care. Advance care planning and goals-of-care conversations ("EOL discussions") may influence EOL health-care utilization and costs among persons with cancer. OBJECTIVE To describe associations among EOL discussions, health-care utilization and place of death, and costs in persons with advanced cancer and explore variation in study measures. METHODS A systematic review was conducted using PubMed, Embase, and CINAHL. Twenty quantitative studies published between January 2012 and January 2019 were included. RESULTS End-of-life discussions are associated with lower health-care costs in the last 30 days of life (median US$1048 vs US$23482; P < .001); lower likelihood of acute care at EOL (odds ratio [(OR] ranging 0.43-0.69); lower likelihood of intensive care at EOL (ORs ranging 0.26-0.68); lower odds of chemotherapy near death (ORs 0.41, 0.57); lower odds of emergency department use and shorter length of hospital stay; greater use of hospice (ORs ranging 1.79 to 6.88); and greater likelihood of death outside the hospital. Earlier EOL discussions (30+ days before death) are more strongly associated with less aggressive care outcomes than conversations occurring near death. CONCLUSIONS End-of-life discussions are associated with less aggressive, less costly EOL care. Clinicians should initiate these discussions with patients having cancer earlier to better align care with preferences.
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Affiliation(s)
- Lauren T Starr
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,2 Penn Center for Bioethics, University of Pennsylvania, Philadelphia, PA, USA.,3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Connie M Ulrich
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,5 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristin L Corey
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Salimah H Meghani
- 1 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial. EGEMS 2019; 7:20. [PMID: 31106226 PMCID: PMC6498873 DOI: 10.5334/egems.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization. Methods: We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input. Results: 2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures. Discussion: A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs. Conclusion: Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.
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Tolle SW, Jimenez VM, Eckstrom E. It is Time to Remove Feeding Tubes From POLST Forms. J Am Geriatr Soc 2019; 67:626-628. [PMID: 30702745 PMCID: PMC7065194 DOI: 10.1111/jgs.15775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/31/2018] [Accepted: 01/01/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Susan W Tolle
- Division of General Internal Medicine and Geriatrics, Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
| | - Valerie M Jimenez
- Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Eckstrom
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon
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Nugent SM, Slatore CG, Ganzini L, Golden SE, Zive D, Vranas KC, Sullivan DR. POLST Registration and Associated Outcomes Among Veterans With Advanced-Stage Lung Cancer. Am J Hosp Palliat Care 2019; 36:564-570. [PMID: 30700127 DOI: 10.1177/1049909118824543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The Oregon Physicians Orders for Life-Sustaining Treatment (POLST) Program allows patients with advanced illness to document end-of-life (EOL) care preferences. We examined the characteristics and associated EOL care among Veterans with and without a registered POLST. METHODS Retrospective, cohort study of advanced-stage (IIIB and IV) patients with lung cancer who were diagnosed between 2008 and 2013 as recorded in the VA Central Cancer Registry. We examined a subgroup of 346 Oregon residents. We obtained clinical and sociodemographic variables from the VA Corporate Data Warehouse and EOL preferences from the Oregon POLST Registry. We compared hospice enrollment and place of death between those with and without a registered POLST. RESULTS Twenty-two (n = 77) percent of our cohort had registered POLST forms. Compared to those without a registered POLST, Veterans with a POLST had a higher income ($51 456 vs $48 882) and longer time between diagnosis and death (223 days vs 119 days). Those with a registered POLST were more likely to be enrolled in hospice (adjusted odds ratio [aOR] = 2.37, 95% confidence interval [CI]: 1.01-5.54) and less likely to die in a VA facility (aOR = 0.27, 95% CI: 0.12-0.59). CONCLUSION There was low submission to the POLST Registry among Veterans who received care in Veterans' Health Administration. Veterans who had a registered POLST were more likely to be enrolled in hospice and less likely to die in a VA care setting. The POLST may improve metrics of high-quality EOL care; however, opportunities for improvement in submission and implementation within the VA exist.
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Affiliation(s)
- Shannon M Nugent
- 1 Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA.,2 Oregon Health and Science University, Portland, OR, USA
| | - Christopher G Slatore
- 1 Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA.,2 Oregon Health and Science University, Portland, OR, USA
| | - Linda Ganzini
- 1 Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA.,2 Oregon Health and Science University, Portland, OR, USA
| | - Sara E Golden
- 1 Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA.,2 Oregon Health and Science University, Portland, OR, USA
| | - Dana Zive
- 2 Oregon Health and Science University, Portland, OR, USA
| | - Kelly C Vranas
- 1 Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA.,2 Oregon Health and Science University, Portland, OR, USA
| | - Donald R Sullivan
- 1 Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA.,2 Oregon Health and Science University, Portland, OR, USA
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Waller A, Turon H, Bryant J, Zucca A, Evans TJ, Sanson-Fisher R. Medical oncology outpatients' preferences and experiences with advanced care planning: a cross-sectional study. BMC Cancer 2019; 19:63. [PMID: 30642289 PMCID: PMC6332530 DOI: 10.1186/s12885-019-5272-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 01/02/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Medical oncology outpatients are a group for whom advance care planning (ACP) activities are particularly relevant. Patient views can help prioritise areas for improving end of life communication. The study aimed to determine in a sample of medical oncology outpatients: (1) the perceived importance of participating in ACP activities; (2) the proportion of patients who have ever participated in ACP activities; and (3) the proportion of patients who had not yet participated in ACP activities who were willing to do so in next month. METHODS Adult medical oncology outpatients in two Australian cancer treatment centres were consecutively approached to complete a pen-and-paper survey. Items explored perceived importance, previous participation, and willingness to participate across key ACP activities including: discussing wishes with their family or doctor; recording wishes in a written document; appointing a substitute decision maker (SDM); and discussing life-expectancy. RESULTS 185 participants completed the survey (51% consent rate). Most patients agreed it was important to: discuss end of life wishes with family (85%) and doctors (70%) and formally record wishes (73%). Few had discussed end of life wishes with a doctor (11%), recorded their wishes (15%); chosen a SDM (28%); discussed life expectancy (30%); or discussed end of life wishes with family (30%). Among those who had not participated in ACP, most were willing to discuss life expectancy (66%); discuss end of life wishes with family (57%) and a doctor (55%); and formally record wishes (56%) in the next month. Fewer wanted to appoint a SDM (40%). CONCLUSION Although medical oncology outpatients perceive ACP activities are important, rates of uptake are relatively low. The willingness of many patients to engage in ACP activities suggests a gap in current ACP practice. Efforts should focus on ensuring patients and families have clarity about the legal and other ramifications of ACP activities, and better education and training of health care providers in initiating conversations about end of life issues.
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Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Heidi Turon
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Alison Zucca
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Tiffany-Jane Evans
- Clinical Research Design and Statistics Support Unit, Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
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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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Zive DM, Jimenez VM, Fromme EK, Tolle SW. Changes Over Time in the Oregon Physician Orders for Life-Sustaining Treatment Registry: A Study of Two Decedent Cohorts. J Palliat Med 2018; 22:500-507. [PMID: 30484728 PMCID: PMC6531902 DOI: 10.1089/jpm.2018.0446] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Dana M Zive
- 1 Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Valerie M Jimenez
- 2 Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
| | - Erik K Fromme
- 3 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan W Tolle
- 4 Division of General Internal Medicine and Geriatrics, Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
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Sequeira ALS, Lewis A. Ethical and Legal Considerations in the Management of an Unbefriended Patient in a Vegetative State. Neurocrit Care 2018; 27:173-179. [PMID: 28484927 DOI: 10.1007/s12028-017-0405-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients without surrogates are referred to as "unbefriended." Because these patients do not have representatives to assist with medical decision-making, patient autonomy and self-determination, fundamental concepts of American healthcare, are jeopardized. METHODS We present a case of an unbefriended patient in a vegetative state and discuss the ethical and legal complications associated with management of unbefriended patients. RESULTS An unbefriended patient was admitted to our hospital with a cardiac arrest in the setting of an intracerebral hemorrhage. Despite aggressive medical and surgical management, he suffered significant brain injury and was in a vegetative state. In our state, unless an unbefriended patient will imminently die despite medical therapy, all measures must be taken to prolong the patient's life, so a tracheostomy and feeding tube were placed and he was transferred to a long-term care facility. The process for making decisions on behalf of unbefriended patients is complicated and varies throughout the country. Some potential ways to avoid these complex situations include: early conversations about treatment wishes while patients have capacity, mandatory advance directives, and increased training and reimbursement for physicians to proactively have end-of-life discussions. CONCLUSION The unbefriended are one of the most high-risk patient groups. Because our patient had no surrogate with whom we could have a goals-of-care discussion, we were obligated to continue aggressive management despite knowing it would prolong, but not improve, his life. Proactive preventative measures to identify and document end-of-life wishes may make management of these patients less ethically and legally complicated.
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Affiliation(s)
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA. .,Department of Neurosurgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA.
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Waller A, Sanson-Fisher R, Ries N, Bryant J. Increasing advance personal planning: the need for action at the community level. BMC Public Health 2018; 18:606. [PMID: 29739369 PMCID: PMC5941331 DOI: 10.1186/s12889-018-5523-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 04/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance personal planning is the process by which people consider, document and communicate their preferences for personal, financial and health matters in case they lose the ability to make decisions or express their wishes in the future. DISCUSSION Advance personal planning is most often undertaken by individuals who are seriously ill, often in the context of a medical crisis and/or at the time of admission to hospital. However, the clinical utility and legal validity of the planning process may be compromised in these circumstances. Patients may lack sufficient capacity to meaningfully engage in advance personal planning; there may be insufficient time to adequately reflect on and discuss wishes with key others; and there may also be limited opportunity for inter-professional input and collaboration in the process. Here, we propose an agenda for research to advance the science of advance personal planning by promoting a 'whole community' approach. Adoption of advance personal planning at a community level may be achieved using a variety of strategies including public media campaigns, intervening with professionals across a range of health care and legal settings, and mobilising support from influential groups and local government. One potentially promising method for encouraging earlier adoption of advance personal planning among a broader population involves a community action approach, whereby multiple evidence-based strategies are integrated across multiple access points. Community action involves calling on community members, professionals, community and/or government organisations to work collaboratively to design and systematically implement intervention strategies with the aim of bringing about desired behaviour change. An example of a community action trial to improving uptake and quality of advance personal planning is described. CONCLUSION While promising, there is a need for rigorous evidence to demonstrate whether a community action approach is effective in establishing whole community adoption of advance personal planning.
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Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Nola Ries
- Faculty of Law, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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Johnson CE, Chong JC, Wilkinson A, Hayes B, Tait S, Waldron N. Goals of patient care system change with video-based education increases rates of advance cardiopulmonary resuscitation decision-making and discussions in hospitalised rehabilitation patients. Intern Med J 2018; 47:798-806. [PMID: 28401688 DOI: 10.1111/imj.13454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/23/2017] [Accepted: 04/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR. AIM To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients. METHODS A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer. RESULTS When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03). CONCLUSION An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care.
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Affiliation(s)
- Claire E Johnson
- School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - Jeffrey C Chong
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia
| | - Anne Wilkinson
- School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Barbara Hayes
- Advance Care Planning Program, Northern Health, Melbourne, Victoria, Australia.,Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sonia Tait
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia
| | - Nicholas Waldron
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia.,Health Strategy and Networks, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Western Australia, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
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O'Brien H, Scarlett S, Brady A, Harkin K, Kenny RA, Moriarty J. Do-not-attempt-resuscitation (DNAR) orders: understanding and interpretation of their use in the hospitalised patient in Ireland. A brief report. JOURNAL OF MEDICAL ETHICS 2018; 44:201-203. [PMID: 29101301 DOI: 10.1136/medethics-2016-103986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 08/10/2017] [Accepted: 09/24/2017] [Indexed: 06/07/2023]
Abstract
Following the introduction of do-not-resuscitate (DNR) orders in the 1970s, there was widespread misinterpretation of the term among healthcare professionals. In this brief report, we present findings from a survey of healthcare professionals. Our aim was to examine current understanding of the term do-not-attempt-resuscitate (DNAR), decision-making surrounding DNAR and awareness of current guidelines. The survey was distributed to doctors and nurses in a university teaching hospital and affiliated primary care physicians in Dublin via email and by hard copy at educational meetings from July to December 2014. A total of 519 completed the survey. The response rate in the hospital doctors group was 35.5% (187/527), 19.8% (292/1477) in the nurses group but 68.8% (150/218) in the specialist nurses group and 40% (40/100) in the primary care physician group.Alarmingly, our results demonstrate that 26.8% of staff nurses and 30% of primary care physicians surveyed believed that a patient with a DNAR order could not receive any/at least one of a list of simple treatments including antibiotics, physiotherapy, intravenous fluids, pain relief, oxygen, nasogastric feeding or airway suctioning, which were higher percentages compared to the other hospital doctors and experienced nurses groups with statistically significant differences (p<0.001). Furthermore, a higher percentage of staff nurses (26.8%) and primary care physicians (22.5%) believed that a patient with a DNAR order could not be referred to hospital from home/a nursing home, when compared with other healthcare groups (p<0.001). Our findings highlight continued misunderstanding and over-interpretation of DNAR orders. Further collaboration and information is required for meaningful Advance Care Plans.
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Affiliation(s)
- Helen O'Brien
- Department of Medical Gerontology, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
| | - Siobhan Scarlett
- Department of Medical Gerontology, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
| | - Anne Brady
- Department of Nursing, Resuscitation Officer, St. James's Hospital, Dublin, Ireland
| | - Kieran Harkin
- Inchicore Family Doctors, Primary Care Centre, St. Michaels Estate, Dublin, Ireland
| | - Rose Anne Kenny
- Department of Medical Gerontology, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
| | - Jeanne Moriarty
- Department of Anaesthesia, St. James's Hospital, Dublin, Ireland
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Turner AM, Osterhage K, Loughran J, Painter I, Demiris G, Hartzler AL, Phelan EA. Emergency information management needs and practices of older adults: A descriptive study. Int J Med Inform 2018; 111:149-158. [PMID: 29425626 DOI: 10.1016/j.ijmedinf.2017.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 09/08/2017] [Accepted: 12/04/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To better understand how older adults currently manage emergency information, the barriers and facilitators to planning and management of emergency information, as well as the potential role of information technology to facilitate emergency planning and management. INTRODUCTION Older adults face a much higher risk of sudden illness/injury and are the age group with the largest percentages of emergent and urgent healthcare visits. Emergency information (health information needed in an emergency situation such as emergency contact information, diagnoses, and advance directives) needs to be maintained and easily accessible to ensure older adults get appropriate care and treatment consistent with their wishes in emergency situations. Current health information technologies rarely take into consideration the emergency information needs of older adults, their caregivers, and emergency responders. METHODS As part of a larger study we performed in-depth interviews with 90 older adults living in a variety of residential settings (independent living, retirement communities, assisted living) regarding how they manage information about their health. Interview sessions included photos of important health information artifacts. Interviews were transcribed and coded. RESULTS Analysis of in-depth interviews revealed that emergency information is a type of health information that older adults frequently manage. Participants differed in whether they practice emergency planning (e.g. the preparation and continued management of emergency information), and in whether they involve others in emergency information and emergency planning. Despite its importance, emergency information was often not up-to-date and not always kept in locations readily apparent to emergency responders. CONCLUSION Emergency information, such as emergency contact information, diagnoses, and advance directives, is a type of health information that older adults manage. Considering emergency information in the design of health information technologies for older adults could address some of the barriers and support the facilitators to emergency planning and information management.
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Affiliation(s)
- Anne M Turner
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA; Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, 850 Republican Street, Box 358047, Seattle, WA, 98195, USA, USA.
| | - Katie Osterhage
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA.
| | - Julie Loughran
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA.
| | - Ian Painter
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA.
| | - George Demiris
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, 850 Republican Street, Box 358047, Seattle, WA, 98195, USA, USA; Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Box 357260, University of Washington, Seattle, WA, 98195, USA, USA.
| | - Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, 850 Republican Street, Box 358047, Seattle, WA, 98195, USA, USA.
| | - Elizabeth A Phelan
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA; Division of Gerontology and Geriatric Medicine, School of Medicine, University of Washington, Harborview Medical Center, 325 9th Ave, Box 359755, Seattle, WA, 98104, USA, USA.
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Abstract
AbstractEthical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The ethics of real-time EMS direction: suggested curricular content. Prehosp Disaster Med. 2018;33(2):201–212.
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Barnette Donnelly C, Armstrong KA, Perkins MM, Moulia D, Quest TE, Yancey AH. Emergency Medical Services Provider Experiences of Hospice Care. PREHOSP EMERG CARE 2017; 22:237-243. [DOI: 10.1080/10903127.2017.1358781] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities. J Am Med Dir Assoc 2017; 18:885-890. [PMID: 28688730 DOI: 10.1016/j.jamda.2017.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/24/2017] [Accepted: 05/24/2017] [Indexed: 12/21/2022]
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.
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Guidelines for Emergency Physicians on the Interpretation of Physician Orders for Life-Sustaining Therapy (POLST). Ann Emerg Med 2017. [DOI: 10.1016/j.annemergmed.2017.04.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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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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Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach. HEC Forum 2017; 28:339-354. [PMID: 27392597 DOI: 10.1007/s10730-016-9305-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.
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Carr D, Luth EA. Advance Care Planning: Contemporary Issues and Future Directions. Innov Aging 2017; 1:igx012. [PMID: 30480109 PMCID: PMC6177019 DOI: 10.1093/geroni/igx012] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 11/30/2022] Open
Abstract
Advance care planning (ACP) is widely considered an essential step toward achieving end-of-life care that is consistent with the preferences of dying patients and their families. ACP comprises a living will and a durable power of attorney for health care (DPAHC); these tools enable patients to articulate and convey their treatment preferences when they are still cognitively intact. In this article, we describe the strengths, weaknesses, and correlates of ACP in the United States, with attention to race and socioeconomic disparities therein. We then discuss other public policies and community programs designed to increase both the number of older adults who articulate their preferences for end-of-life care, and efficacy of ACP for ensuring that patients' end-of-life treatment preferences are met. We describe the characteristics, strengths, and limitations of Physician Orders for Life Sustaining Treatment (POLSTs), and describe community programs, educational interventions, and public policies aimed toward increasing the prevalence and efficacy of end-of-life preparations. A key policy advance in the early 2010s has been Medicare coverage of one doctor-patient consultation session regarding end-of-life issues; we highlight the potentials and possible pitfalls of this policy. We conclude by identifying areas for future research, and highlighting practices from other nations that may help improve quality of end-of-life care in the United States.
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Affiliation(s)
- Deborah Carr
- Department of Sociology, Boston University, Massachusetts
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Abbott J. Understanding What People Intend: Is It Possible From Written Advance Directives? J Am Med Dir Assoc 2017; 18:10-11. [DOI: 10.1016/j.jamda.2016.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 12/01/2022]
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Rahman AN, Bressette M, Enguidanos S. Quality of Physician Orders for Life-Sustaining Treatment Forms Completed in Nursing Homes. J Palliat Med 2016; 20:538-541. [PMID: 27841953 DOI: 10.1089/jpm.2016.0280] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The physician orders for life-sustaining treatment (POLST) form allows seriously ill individuals to express their preferences for end-of-life treatments. Despite increased POLST use, little is known about the quality of completed forms. OBJECTIVE We examined the quality of POLST forms prepared for nursing home residents, including whether they had required signatures and clinically consistent care preferences. DESIGN We conducted a chart review of POLST forms for a sample of nursing home residents in California. SETTING/SAMPLE We completed POLST audits for 938 residents in 13 nursing homes in Los Angeles. MEASURES We recorded whether POLST forms were signed by both the patient (or proxy) and the physician, and whether the patient's treatment choices regarding resuscitation and medical intervention were consistent, as required by the California form. RESULTS Overall, 69.6% of audited POLST forms had at least one indicator of poor quality. Most lacked a required signature (15.8% lacked a physician signature and 17.4% lacked a patient/proxy signature) and 5.6% had conflicting treatment preferences. CONCLUSION We found 30.4% of POLST forms for nursing home residents were not complete or documented clinically contradictory treatment preferences. Improvement in the quality of POLST forms is needed.
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Affiliation(s)
- Anna N Rahman
- 1 Gerontology Research Consultant, Los Angeles, California.,2 Davis School of Gerontology, University of Southern California , Los Angeles, California
| | - Matthew Bressette
- 2 Davis School of Gerontology, University of Southern California , Los Angeles, California
| | - Susan Enguidanos
- 2 Davis School of Gerontology, University of Southern California , Los Angeles, California
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Hayes SA, Zive D, Ferrell B, Tolle SW. The Role of Advanced Practice Registered Nurses in the Completion of Physician Orders for Life-Sustaining Treatment. J Palliat Med 2016; 20:415-419. [PMID: 27767363 PMCID: PMC5385423 DOI: 10.1089/jpm.2016.0228] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms. Objective: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms. Design: Cross-sectional. Setting/subjects: 226,101 Oregon POLST Registry forms from 2010 to 2015. Measurements: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA). Results: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign. Conclusions: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.
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Affiliation(s)
- Sophia A Hayes
- 1 School of Medicine, Oregon Health & Science University , Portland, Oregon
| | - Dana Zive
- 2 Center for Policy and Research in Emergency Medicine, Oregon Health & Science University , Portland, Oregon
| | - Betty Ferrell
- 3 Division of Nursing Research and Education, Department of Population Sciences, Beckman Research Institute of City of Hope , Duarte, California
| | - Susan W Tolle
- 4 Division of General Internal Medicine and Geriatrics, Center for Ethics in Health Care, Oregon Health & Science University , Portland, Oregon
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Zive DM, Cook J, Yang C, Sibell D, Tolle SW, Lieberman M. Implementation of a Novel Electronic Health Record-Embedded Physician Orders for Life-Sustaining Treatment System. J Med Syst 2016; 40:245. [PMID: 27696173 DOI: 10.1007/s10916-016-0605-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 09/12/2016] [Indexed: 11/28/2022]
Abstract
In April 2015, Oregon Health & Science University (OHSU) deployed a web-based, electronic medical record-embedded application created by third party vendor Vynca Inc. to allow real-time education, and completion of Physician Orders for Life Sustaining Treatment (POLST). Forms are automatically linked to the Epic Systems™ electronic health record (EHR) patient header and submitted to a state Registry, improving efficiency, accuracy, and rapid access to and retrieval of these important medical orders. POLST Forms, implemented in Oregon in 1992, are standardized portable medical orders used to document patient treatment goals for end-of-life care. In 2009, Oregon developed the first POLST-only statewide registry with a legislative mandate requiring POLST form signers to register the form unless the patient opts out. The Registry offers 24/7 emergency access to POLST Forms for Emergency Medical Services, Emergency Departments, and Acute Care Units. Because POLST is intended for those nearing end of life, immediate access to these forms at the time of an emergency is critical. Delays in registering a POLST Form may result in unwanted treatment if the paper form is not immediately available. An electronic POLST Form completion system (ePOLST) was implemented to support direct Registry submission. Other benefits of the system include single-sign-on, transmission of HL7 data for patient demographics and other relevant information, elimination of potential errors in form completion using internalized logic, built-in real-time video and text-based education materials for both patients and health care professionals, and mobile linkage for signature capture.
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Affiliation(s)
- Dana M Zive
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239-3098, USA.
| | - Jennifer Cook
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239-3098, USA
| | - Charissa Yang
- Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - David Sibell
- Ambulatory Informatics, Clinical Informatics Department, Oregon Health & Science University (OHSU), Portland, OR, 97239, USA
| | - Susan W Tolle
- Center for Ethics in Health Care and Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, 97239, USA
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Clemency B, Cordes CC, Lindstrom HA, Basior JM, Waldrop DP. Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care. J Am Med Dir Assoc 2016; 18:35-39. [PMID: 27692663 DOI: 10.1016/j.jamda.2016.07.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/29/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. PROCEDURES MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the "other instructions" section were submitted to content analysis. RESULTS Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for "comfort measures only" seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. CONCLUSIONS Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.
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Affiliation(s)
- Brian Clemency
- Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, NY
| | | | - Heather A Lindstrom
- Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, NY
| | - Jeanne M Basior
- Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, NY
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Patel MI, Bhattacharya J, Asch SM, Kahn J. Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer. Am J Hosp Palliat Care 2016; 33:742-7. [DOI: 10.1177/1049909115595216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer. Methods: We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral. Results: Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC. Discussion: We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jay Bhattacharya
- Health Policy & Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven M. Asch
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, USA
| | - James Kahn
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, USA
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Evans J, Ball L, Wicher C. Implementation of Medical Orders for Life-Sustaining Treatment. Clin J Oncol Nurs 2016; 20:74-8. [DOI: 10.1188/16.cjon.74-78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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