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Kuroda K, Ito K, Uemura T. Unwanted cardiopulmonary resuscitation against patients' "Do Not Attempt Resuscitation" orders in community settings in Japan: A narrative review. Geriatr Gerontol Int 2024; 24:1093-1098. [PMID: 39353588 DOI: 10.1111/ggi.14993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 09/14/2024] [Accepted: 09/17/2024] [Indexed: 10/04/2024]
Abstract
We aimed to synthesize existing research to elucidate the underlying factors and causes responsible for the high prevalence of unwanted cardiopulmonary resuscitation (CPR) occurring outside a hospital setting in Japan despite patients' Do Not Attempt Resuscitation (DNAR) orders. We conducted a narrative review by searching PubMed, EMBASE, and Scopus for English literature, and Google Scholar for Japanese literature. The key factors we identified included lack of documentation of resuscitation preferences, variation in the perception of other life-sustaining measures associated with DNAR, non-inclusion of the patient in discussions of goals of care, unlegislated and unstandardized DNAR orders, emergency medical service activation by the family or facility, the Fire Service Act that mandates life-saving measures irrespective of the presence of advance directives, fire department protocols and CPR decision-making, and death pronouncement authorization limited to physicians. This study identified the multifaceted factors and the potential triggers for unwanted CPR despite DNAR orders. These findings underscore the urgent need for comprehensive interventions encompassing educational initiatives, ethical considerations, systemic reforms, and legal adjustments to prevent future unwanted CPRs in Japan. Geriatr Gerontol Int 2024; 24: 1093-1098.
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Affiliation(s)
- Kaku Kuroda
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester, Rochester, New York, USA
- Department of General Internal Medicine, University of Toyama, Toyama, Japan
| | - Kaori Ito
- Department of Surgery, Division of Acute Care Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takeshi Uemura
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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2
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Tanious M, Lindvall C, Cooper Z, Tukan N, Peters S, Streid J, Fields K, Bader A. Prevalence, Management, and Outcomes Related to Preoperative Medical Orders for Life Sustaining Treatment (MOLST) in an Adult Surgical Population: Preoperative MOLST and Code Status Discussions. Ann Surg 2023; 277:109-115. [PMID: 33351480 DOI: 10.1097/sla.0000000000004675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine prevalence of documented preoperative code status discussions and postoperative outcomes (specifically mortality, readmission, and discharge disposition) of patients with completed MOLST forms before surgery. SUMMARY OF BACKGROUND DATA A MOLST form documents patient care preference regarding treatment limitations. When considering surgery in these patients, preoperative discussion is necessary to ensure concordance of care. Little is known about prevalence of these discussions and postoperative outcomes. METHODS A retrospective cohort study was conducted consisting of all patients having surgery during a 1-year period at a tertiary care academic center in Boston, Massachusetts. RESULTS Among 21,787 surgical patients meeting inclusion criteria, 402 (1.8%) patients had preoperative MOLST. Within the MOLST, 224 (55.7%) patients had chosen to limit cardiopulmonary resuscitation and 214 (53.2%) had chosen to limit intubation and mechanical ventilation. Code status discussion was documented presurgery in 169 (42.0%) patients with MOLST. Surgery was elective or nonurgent for 362 (90%), and median length of stay (Q1, Q3) was 5.1 days (1.9, 9.9). The minority of patients with preoperative MOLST were discharged home [169 (42%), and 103 (25.6%) patients were readmitted within 30 days. Patients with preoperative MOLST had a 30-day mortality of 9.2% (37 patients) and cumulative 90-day mortality of 14.9% (60 patients). CONCLUSIONS Fewer than half of surgical patients with preoperative MOLST have documented code status discussions before surgery. Given their high risk of postoperative mortality and the diversity of preferences found in MOLST, thoughtful discussion before surgery is critical to ensure concordant perioperative care.
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Affiliation(s)
- Mariah Tanious
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina
| | - Charlotta Lindvall
- Department of Palliative Medicine, Dana Farber Cancer Institute, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Department of Palliative Medicine, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalie Tukan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Peters
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jocelyn Streid
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kara Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Angela Bader
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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3
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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: 4] [Impact Index Per Article: 2.0] [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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4
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Charlton P, Kean T, Liu RH, Nagel DA, Azar R, Doucet S, Luke A, Montelpare W, Mears K, Boulos L. Use of environmental scans in health services delivery research: a scoping review. BMJ Open 2021; 11:e050284. [PMID: 34758992 PMCID: PMC8587593 DOI: 10.1136/bmjopen-2021-050284] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To examine the extent and nature of evidence on the use of the environmental scan (ES) in the health services delivery literature. DESIGN Scoping review. METHODS This scoping review followed the five-stage scoping review methodology outlined by Khalil et al. A Peer Review of Electronic Search Strategies was completed. Seven electronic databases and the grey literature were searched. Pairs of researchers independently performed two levels of screening and data extraction. Data were analysed using qualitative content and thematic analysis. RESULTS Ninety-six studies were included in the scoping review. Researchers conducted ESs for many purposes, the most common being to examine the current state of programmes, services or policies. Recommendations were informed by ESs in 20% of studies. Most common data collection methods were literature review (71%), key informant or semistructured interviews (46%) and surveys (35%). Over half (53%) of the studies used a combination of passive (looking at information eg, literature, policies, guidelines) and active (looking for information eg, surveys, interviews) approaches to data collection. Person sources of data (eg, healthcare stakeholders, community representatives) and non-person sources of data (eg, documents, electronic databases, the web) were drawn on to a similar extent. The thematic analysis of the definitions/descriptions yielded several themes including instrument of discovery, knowledge synthesis, forward-looking and decision making. Research gaps identified included absence of a standard definition, inconsistencies in terminology and lack of guiding frameworks in the health services delivery context. CONCLUSION ESs were conducted to gather evidence and to help inform decision making on a range of policy and health services delivery issues across the continuum of care. Consistency in terminology, a consensus definition and more guidance on ES design may help provide structure for researchers and other stakeholders, and ultimately advance ES as a methodological approach. A working definition of ES in a health services delivery context is presented.
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Affiliation(s)
- Patricia Charlton
- Adjunct Faculty, Faculty of Nursing, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Terri Kean
- Faculty of Nursing, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Rebecca H Liu
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Daniel A Nagel
- College of Nursing, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Rima Azar
- Psychobiology of Stress and Health Lab, Psychology Department, Mount Allison University, Sackville, New Brunswick, Canada
| | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - William Montelpare
- Department of Applied Human Sciences, Faculty of Science, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Kim Mears
- Robertson Library, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Leah Boulos
- Maritime SPOR SUPPORT Unit, Halifax, Nova Scotia, Canada
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Fu CJ, Agarwal M, Estrada LV, Murali KP, Quigley DD, Dick AW, Stone PW. The Role of Regional and State Initiatives in Nursing Home Advance Care Planning Policies. Am J Hosp Palliat Care 2021; 38:1135-1141. [PMID: 33111537 PMCID: PMC8079519 DOI: 10.1177/1049909120970117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Antibiotic use at the end of life (EoL) may introduce physiological as well as psychological stress and be incongruent with patients' goals of care. Advance care planning (ACP) related to antibiotic use at the EoL helps improve goal-concordant care. Many nursing home (NH) residents are seriously ill. Therefore, we aimed to examine whether state and regional ACP initiatives play a role in the presence of "do not administer antibiotics" orders for NH residents at the EoL. METHODS We surveyed a random, representative national sample of 810 U.S. NHs (weighted n = 13,983). The NH survey included items on "do not administer antibiotics" orders in place and participation in infection prevention collaboratives. The survey was linked to state Physician Orders for Life-Sustaining Treatment (POLST) adoption status and resident, facility, and county characteristics data. We conducted multivariable regression models with state fixed effects, stratified by state POLST designation. RESULTS NHs in mature POLST states reported higher rates of "do not administer antibiotics" orders compared to developing POLST states (10.1% vs. 4.6%, respectively, p = 0.004). In mature POLST states, participation in regional collaboratives and smaller NH facilities (<100 beds) were associated with having "do not administer antibiotics" orders for seriously ill residents (β = 0.11, p = 0.006 and β = 0.12, p = 0.003, respectively). DISCUSSION NHs in states with mature POLST adoption that participated in infection control collaboratives were more likely to have "do not administer antibiotics" orders. State ACP initiatives combined with regional antibiotic stewardship initiatives may improve inappropriate antibiotic use at the EoL for NH residents.
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Affiliation(s)
- Caroline J. Fu
- Columbia University School of Nursing, 560 West 168 Street, New York, NY, USA
| | - Mansi Agarwal
- Columbia University School of Nursing, 560 West 168 Street, New York, NY, USA
| | - Leah V. Estrada
- Columbia University School of Nursing, 560 West 168 Street, New York, NY, USA
| | - Komal P. Murali
- Columbia University School of Nursing, 560 West 168 Street, New York, NY, USA
| | | | - Andrew W. Dick
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
| | - Patricia W. Stone
- Columbia University School of Nursing, 560 West 168 Street, New York, NY, USA
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6
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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: 2] [Impact Index Per Article: 0.7] [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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7
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Kates OS, Krantz EM, Lee J, Klaassen J, Morris J, Mezheritsky I, Sweet A, Tverdek F, Loggers ET, Pergam SA, Liu C. Association of Physician Orders for Life-Sustaining Treatment With Inpatient Antimicrobial Use at End of Life in Patients With Cancer. Open Forum Infect Dis 2021; 8:ofab361. [PMID: 34395710 PMCID: PMC8360239 DOI: 10.1093/ofid/ofab361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/02/2021] [Indexed: 11/14/2022] Open
Abstract
Background Antimicrobial utilization at end of life is common, but whether advance directives correlate with usage is unknown. We sought to determine whether Washington State Physician Orders for Life Sustaining Treatment (POLST) form completion or antimicrobial preferences documented therein correlate with subsequent inpatient antimicrobial prescribing at end of life. Methods This was a single-center, retrospective cohort study of adult patients at a cancer center who died between January 1, 2016, and June 30, 2019. We used negative binomial models adjusted for age, sex, and malignancy type to test the relationship between POLST form completion ≥30 days before death, antimicrobial preferences, and antimicrobial days of therapy (DOT) per 1000 inpatient-days in the last 30 days of life. Results Among 1295 eligible decedents with ≥1 inpatient-day during the last 30 days of life, 318 (24.6%) completed a POLST form. Of 318, 120 (37.7%) were completed ≥30 days before death, 35/120 (29.2%) specified limited antimicrobials, 55/120 (45.8%) specified full antimicrobial use, and 30/120 (25%) omitted antimicrobial preference. Eighty-three percent (1070/1295) received ≥1 inpatient antimicrobial. The median total and intravenous (IV) antimicrobial DOT/1000 inpatient-days were 1077 and 667. Patients specifying limited antimicrobials had significantly lower total antimicrobial DOT (adjusted incidence rate ratio [IRR], 0.68; 95% CI, 0.49-0.95; P = .02) and IV antimicrobial DOT (IRR, 0.57; 95% CI, 0.38-0.86; P = .008) compared with those without a POLST. Conclusions Indicating a preference for limited antimicrobials on a POLST form ≥30 days before death may lead to less inpatient antimicrobial use in the last 30 days of life.
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Affiliation(s)
- Olivia S Kates
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Juhye Lee
- Department of Basic Sciences and Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - John Klaassen
- Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Jessica Morris
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Ania Sweet
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Frank Tverdek
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Elizabeth T Loggers
- Seattle Cancer Care Alliance, Seattle, Washington, USA.,Division of Oncology, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Steven A Pergam
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
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8
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Tolle SW. Aligning POLST orders with wishes: Time to put evidence into practice. J Am Geriatr Soc 2021; 69:1801-1804. [PMID: 33826762 PMCID: PMC8360100 DOI: 10.1111/jgs.17150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Susan W Tolle
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University Center for Ethics in Health Care, Portland, Oregon, USA
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9
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Harrison JM, Agarwal M, Stone PW, Gracner T, Sorbero M, Dick AW. Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents? J Palliat Med 2021; 24:1334-1341. [PMID: 33605787 DOI: 10.1089/jpm.2020.0577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA
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10
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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: 8] [Impact Index Per Article: 2.0] [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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11
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Tark A, Song J, Parajuli J, Chae S, Stone PW. Are We Getting What We Really Want? A Systematic Review of Concordance Between Physician Orders for Life-Sustaining Treatment (POLST) Documentation and Subsequent Care Delivered at End-of-Life. Am J Hosp Palliat Care 2020; 38:1142-1158. [PMID: 33251826 DOI: 10.1177/1049909120976319] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Physician Orders for Life-Sustaining Treatments (POLST) is an advance care planning (ACP) tool that is designed to facilitate End-of-Life (EoL) care discussions between a medical provider and a terminally ill patient. It is often used as a tool to translate care wishes into a medical order, which can be honored across healthcare settings. With an increased utilization of the POLST paradigm in various healthcare settings along with continued dissemination across the nation, it is critical to examine whether documented wishes on POLST are concordant with subsequent care delivered. Purpose of this article was to examine concordance rate between POLST and subsequent care delivered in any care settings and communities. DESIGN Systematic review. RESULTS Of 1,406 articles identified, 10 articles met inclusion criteria. Together, included studies represent 5,688 POLST forms reviewed from individuals residing in a total of 126 nursing care facilities, 9 elderly care centers, 4 community settings, and 2 hospitals. Preference for cardiopulmonary resuscitation and actual delivery/ withholding of resuscitation was the most observed intervention in study of concordance (n = 8). It is also where highest concordance rate (97.5%) was reported. Seven studies compared care provided during EoL and the level of medical intervention requested on POLST forms (91.17% concordance). Preference to use artificial nutrition/ hydration, and actual delivery was 93.0% (n = 4 studies), and antibiotics use preference and delivery was 96.5% (reported in 4 studies). CONCLUSION Published literature evidence suggests that EoL care wishes documented on POLST forms were largely concordant with subsequent care delivered. Additional research is needed to evaluate concordance between POLST documentation and care received among POLST users, who experienced multiple care transitions across healthcare settings, or across state during EoL care journey.
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Affiliation(s)
- Aluem Tark
- 4083University of Iowa College of Nursing, Iowa City, IA, USA
| | - Jiyoun Song
- 5798Columbia University School of Nursing, New York, NY, USA
| | | | - Sena Chae
- 4083University of Iowa College of Nursing, Iowa City, IA, USA
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12
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Tark A, Agarwal M, Dick AW, Song J, Stone PW. Impact of the Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the Nursing Home Resident's Place of Death. Am J Hosp Palliat Care 2020; 38:812-822. [PMID: 32878457 DOI: 10.1177/1049909120956650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The Physician Orders for Life-Sustaining Treatment (POLST) program was developed to enhance quality of care delivered at End-of-Life (EoL). Although positive impacts of the POLST program have been identified, the association between a program maturity status and nursing home resident's likelihood of dying in their current care settings remain unanswered. This study aims to evaluate the impact of the POLST program maturity status on nursing home residents' place of death. Using multiple national-level datasets, we examined total 595,152 residents and their place of death. The result showed that the long-stay residents living in states where the program was mature status had 12% increased odds of dying in nursing homes compared that of non-conforming status. Individuals residing in states with developing program status showed 11% increase in odds of dying in nursing homes. The findings demonstrate that a well-structured and well-disseminated POLST program, combined with a continued effort to meet high standards of quality EoL care, can bring out positive health outcomes for elderly patients residing in care settings.
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Affiliation(s)
- Aluem Tark
- Columbia University School of Nursing, New York, NY, USA.,4083University of Iowa College of Nursing, Iowa City, IA, USA
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY, USA
| | | | - Jiyoun Song
- Columbia University School of Nursing, New York, NY, USA
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13
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Baker EF, Marco CA. Advance directives in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:270-275. [PMID: 33000042 PMCID: PMC7493570 DOI: 10.1002/emp2.12021] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.
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Affiliation(s)
- Eileen F. Baker
- University of Toledo College of Medicine and Life SciencesToledoOhio
- Riverwood Emergency Services, Inc.PerrysburgOhio
| | - Catherine A. Marco
- Department of Emergency MedicineWright State University Boonshoft School of MedicineDaytonOhio
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14
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Tark A, Agarwal M, Dick AW, Stone PW. Response to Jimenez et al. (doi: 10.1089/jpm.2019.0181) Response to Tark et al.: Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan. J Palliat Med 2019; 22:1022. [PMID: 31498728 DOI: 10.1089/jpm.2019.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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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15
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Stone PW, Agarwal M, Ye F, Sorbero M, Miller SC, Dick AW. Integration of Palliative Care and Infection Management at the End of Life in U.S. Nursing Homes. J Pain Symptom Manage 2019; 58:408-416.e1. [PMID: 31195078 PMCID: PMC6708746 DOI: 10.1016/j.jpainsymman.2019.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/13/2019] [Accepted: 06/03/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT Infections in nursing home (NH) residents are often terminal illnesses. Integration of palliative care (PC) and infection management (IM) is a new concept that can help reduce burdensome treatments and improve quality of care for NH residents at the end of life. OBJECTIVES To develop measures of integration, describe the integration in U.S. NHs, and examine predictors of integration. METHODS A nationally representative sample of NHs was surveyed. An instrument to measure integration was tested using factor analyses. Descriptive analyses of each integration factor were conducted, construct validity was examined using correlations between the integration factors and validated measures of PC and IM, and multivariable linear regression models were developed to identify NH characteristics associated with integration. RESULTS A total of 892 NH surveys were returned (49% response rate), 859 with complete data. Three integration factors were identified: patient involvement in care planning (Involvement), formalized advance care planning (Advance Care Planning), and routine practices of integration (Routine Practices). The highest level of integration in NHs was reported for Involvement (mean (μ) = 73.2, standard error [SE] = 1.57), with lower rates for Advance Care Planning and Routine Practices (respectively, μ = 34.1, SE = 1.05; μ = 31.4, SE = 1.48). Each integration measure was weakly, positively associated with the PC and IM measures (r ≤ 0.25, P ≤ 0.01). There were few associations between NH characteristics and integration. CONCLUSION Integration is a distinct concept that is associated with, but different from, PC and IM. Results serve as a baseline assessment of integration in NHs. Continued refinement of the integration instrument is recommended, as is studying if higher integration leads to better resident outcomes.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA.
| | - Feifei Ye
- RAND Corporation, Pittsburgh, Pennsylvania, USA
| | | | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
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16
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Giger M, Voneschen N, Brunkert T, Zúñiga F. Care workers' view on factors leading to unplanned hospitalizations of nursing home residents: A cross-sectional multicenter study. Geriatr Nurs 2019; 41:110-117. [PMID: 31447139 DOI: 10.1016/j.gerinurse.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022]
Abstract
Nursing home residents have a high risk of adverse events during hospitalizations. Since up to two-thirds of hospitalizations of nursing home residents are rated as potentially preventable, this study aimed to describe factors related to unplanned hospitalizations and to describe rates of unplanned hospitalizations, comparing differences between high- and low-hospitalization nursing homes. This cross-sectional multicenter study was conducted in 19 Swiss nursing homes and used questionnaire surveys of ward supervisors (n = 33) and nursing staff (n = 146) and retrospectively assessed hospitalization data. The study revealed several issues regarding unplanned hospitalizations, mostly concerning limitations regarding physicians' availability, lack of acquaintance of on-call physicians with the residents, and health professionals' lack of knowledge about the residents' wishes concerning therapeutic decisions. Our findings suggest that standardizing advance care planning processes and better physician availability might further reduce hospitalizations and improve quality of care in nursing homes.
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Affiliation(s)
- Max Giger
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, Basel 4056, Switzerland.
| | - Nina Voneschen
- Alterszentrum Wiesendamm, Wiesendamm 20, Basel 4057, Switzerland.
| | - Thekla Brunkert
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, Basel 4056, Switzerland.
| | - Franziska Zúñiga
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, Basel 4056, Switzerland.
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Jimenez VM, Dotson A, Tolle SW. Response to Tark et al. (doi: 10.1089/jpm.2018.0626): Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan. J Palliat Med 2019; 22:1020-1021. [PMID: 31009272 PMCID: PMC6735316 DOI: 10.1089/jpm.2019.0181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Valerie M Jimenez
- Center for Ethics in Health Care, Oregon Health and Science University, Portland, Oregon
| | - Abby Dotson
- Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Susan W Tolle
- Division of General Internal Medicine and Geriatrics, Center for Ethics in Health Care, Oregon Health and Science University, Portland, Oregon
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