Life-Sustaining Treatment Form Research Articles

A Quality Improvement Initiative to Increase Documentation of Preferences for Life-Sustaining Treatment in Hospitalized Adults

Portable Orders for Life-Sustaining Treatment (POLST) forms allow patients to codify their preferences for life-sustaining treatments across inpatient and outpatient settings. In 2019 only 29.5% of our hospitalized internal medicine patients with an inpatient do-not-resuscitate (DNR) order and no DNR POLST at admission discharged with a DNR POLST. This presented an opportunity to improve POLST completion and avoid undesired or inappropriate care after discharge. Using electronic health record (EHR) data, the authors identified hospitalized adults (age ≥ 50 years) admitted to an internal medicine service with a DNR order and discharged alive. Patient records were cross-referenced with the state's POLST registry for an active POLST form. Among patients with a missing or full-code POLST form at admission, the authors calculated the proportion with a DNR POLST form completed by discharge. These data were tracked over time with control charts to detect performance shifts following three Plan-Do-Study-Act (PDSA) cycles over 34 months, which included a single educational training on electronic POLST navigation, an EHR discharge navigator notification, and quarterly e-mailed individualized performance reports. The study population (N = 387) was 55.0% male and predominately non-Hispanic white (80.9%). Patients discharging to a skilled nursing facility or hospice were three times more likely to discharge with a DNR POLST compared to patients discharging home. Overall, the proportion of DNR POLST forms completed by discharge increased from 0.36 to 0.60 after three PDSA cycles (p < 0.001). This quality improvement initiative demonstrated improved POLST form completion rates in a target population of adults at elevated risk for readmission and death.

Implementation of a palliative care consultation trigger tool for hospitalised patients with acute decompensated heart failure

Heart failure is a leading cause of hospitalisations. Integration of palliative care services with medical therapy in the management of hospitalised patients with heart failure is imperative. Unfortunately, there are...

Breaking the Readmission Cycle

Breaking the Readmission Cycle Brian Hatten I want to share the story of my difficult patient Ms. L. She has twenty-seven current medical issues. Thirty-five active prescriptions. Limited mobility requiring the use of a motorized scooter. Non-medical care gaps. And over twenty hospital admissions since 2020. I met Ms. L approximately five years ago as her hospital attending and have continued to care for her during her frequent hospitalizations. I could recite this 77-year-old female's litany of medical problems. But sufficed to say, her history is complex, with her admitting diagnoses running the gambit from cellulitis to gastrointestinal bleeding to altered mental status. But, her diagnosis and frequent exacerbations of congestive heart failure (CHF) are particularly frustrating for us both and will be my focus today. CHF makes her susceptible to fluid overload leading to feelings of shortness of breath, which progresses to respiratory distress. Like other individuals with CHF, she uses diuretics to prevent herself from becoming fluid overloaded. And, like many individuals who take diuretics, she hates them. She (un)affectionately calls her water pills "the bomb" because the effect is sudden, profound, and explosive when they begin working. The combination of the diuretic effect and her limited mobility causes significant emotional stress for Ms. L, a woman who values presenting herself outwardly as in control, well-dressed, and put together. Her dislike of the medical effect of her diuretics has led to her either taking them less often or outright discontinuing them. So, while discontinuation avoids those frustrating effects, it leads to fluid accumulation, subsequent respiratory distress, and readmission to the hospital. Her medical records mention she has memory issues. It is unclear how much her mild cognitive impairment affects her frequent readmissions. We have had many conversations where I would never suspect something was amiss. But sometimes, she can be forgetful and does not recall our recent discussions. That being said, she knows the names and uses of her medications. She can report to me her home weights when she checks them and knows what her "dry" weight should be. Yet, she does not act when her scales begin reading heavier or when she develops leg swelling. Instead, she presents to the emergency department in extremis. When directly questioned about why she lets her situation deteriorate to such a state that she requires hospitalization, she demurs. She comments that she can often be stubborn, that the diuretic effect of "the bomb" is burdensome, but always reminds me she is honest in admitting she wasn't taking her water pills. During several admissions, I worried for her survival after she had self-discontinued her medications and showed up at the emergency department in respiratory failure. For any patient with recurrent admissions, I discuss their overall goals of care to ensure we are working together toward achievable medical ends. But this conversation was essential to have with Ms. L. The possibility existed that she would present to the hospital too late in her disease process, and we would not be able to correct her respiratory failure. I wanted to ensure that the hospital staff and I respected her wishes regarding her care. Despite raising my concerns, she would [End Page 22] decline to discuss her wishes. Even worse, attempting to have her complete advance care planning documents like advance directives or a Physician Orders for Life-Sustaining Treatment (POLST) form was a futile endeavor. Ms. L was always vague and non-committal. She simply did not want to engage in those types of conversations. When asked why she declined to discuss these issues, Ms. L would reply that she was doing okay, the discussion was unnecessary, and she had family members to make those decisions for her. Caring for her during her hospital stays was a source of professional frustration for me. Her recurrent admissions made me feel like I was failing her. During each hospital stay, we would go over her medications. We repeatedly discussed how she should check her weights daily and monitor for lower extremity edema. We created multiple action plans for when to call her physicians so we could head off another hospital visit. We completed all the...

DO DIFFERENT ADVANCE DIRECTIVES CREATE CONFUSION ON A PATIENT'S WISHES? (MOLST VERSUS FIVE WISHES)

Abstract Introduction. The objective of this study is to compare perspectives of young adults toward advance directives (ADs) and their preferences for life-sustaining treatment and care options. Methods. Participants include graduate students (n=30) attending a New York State university. Data were collected using a structured survey questionnaire, the Medical Orders for Life-Sustaining Treatment (MOLST) form and the Five Wishes form. Summary statistics were performed to address the study aim. Results. Of the participants, the average age was 24 years (60% were female, 60% White, and 27% Black). In Five Wishes, participants who are close to death, 70% wanted all or some forms of life support; when in a coma (47%), or with permanent and severe brain damage (36.6%) chose similar options. In MOLST, without pulse and/or breathing, 87% want CPR; while with pulse and breathing, 96% want artificially administered fluids and nutrition, 90% want mechanical ventilation, 67% want to be hospitalized, 67% want antibiotics, and 53% want unlimited interventions. Conclusion. (1) The majority of participants had not previously completed an AD; however, they were capable of making decisions about their life-sustaining treatments. (2) The discrepancies in treatment preferences may be due to the language of advance directives. Further studies in this respect are warranted.

Prevalence of Advanced Care Planning in Emergency General Surgery: Do We Know Our Patient’s Goals?

INTRODUCTION: Advanced care planning (ACP) promotes the delivery of goal-concordant, patient-centered surgical care. There is opportunity to increase ACP adoption in surgery. We hypothesized that, on the emergency general surgery (EGS) service, most patients were not engaged in ACP discussions. METHODS: All patients admitted to the EGS service in 2019 were included. The primary outcome was having electronic health record ACP documentation (advance directive, physician order for life-sustaining treatment form [POLST], or ACP note). Multivariate analysis was conducted to identify predictors of ACP. RESULTS: Among 734 patients, the prevalence of ACP on admission was 15% (n = 109), and the prevalence of ACP completed during the hospitalization was 6% (n = 44). Only 27% (n = 12) of inpatient ACP was completed in the hospital before EGS procedures. Most documentation included advanced directives and POLST uploaded before admission (60%, n = 93), and 39 (22%) constituted ACP notes by the surgical team. Multivariable analysis demonstrated increasing age, Medicaid or Medicare insurance, increased length of stay, and institution-concordant primary care were associated with an increased odds of having ACP (Fig. 1); low English language proficiency, an increasing neighborhood deprivation index, and a higher Charlson Comorbidity score were all associated with lower odds of having ACP documentation (Fig. 1).Figure 1CONCLUSION: Integration of ACP for patients receiving EGS care is limited, with significant variation in terms of type of documentation. Little documentation is done in the context of their acute surgical condition. Further study is needed to identify opportunities and barriers to increasing ACP uptake into EGS workflows.

Missed Opportunities and Health Disparities for Advance Care Planning Before Elective Surgery in Older Adults

Advance care planning (ACP) prepares patients and caregivers for medical decision-making, yet it is underused in the perioperative surgical setting, particularly among older adults undergoing high-risk procedures who are at risk for postoperative complications. It is unknown what patient factors are associated with perioperative ACP documentation among older surgical patients. To assess ACP documentation among high-risk patients 65 years and older undergoing elective surgery. In this observational cohort study including 3671 patients 65 years and older undergoing elective surgery at a tertiary academic center in California, electronic health record data were linked to the National Surgical Quality Improvement Project outcomes data and the California statewide death registry. The study was conducted from January 1 to December 31, 2019. Data were analyzed from January to May 2022. Elective surgery requiring an inpatient admission. ACP documentation, defined as a discussion regarding goals of care documented in an ACP note, an advance directive, or a physician order for life-sustaining treatment (POLST) form, within 90 days before elective surgery requiring inpatient admission. Multivariate regression was performed to identify factors associated with missing ACP. Among 3671 patients (median [IQR] age 72 [65-94] years; 1784 [48.6%] female; 401 [10.9%] Asian, 155 [4.2%] Black, 284 [7.7%] Latino/Latina, 2647 [72.1%] White, and 184 [5.0%] of other races or ethnicities, including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, other, and unknown or declined to respond, combined owing to small numbers), 539 (14.7%) had ACP documentation in the 90-day presurgery window. Of these 539, 448 (83.1%) had advance directives, and 60 (11.1%) had POLST forms. The 30-day and 1-year mortality were 0.7% (n = 27) and 6.6% (n = 244), respectively. Missing ACP was significantly associated with male sex (adjusted odds ratio [aOR], 1.39; 95% CI, 1.14-1.69) and having a non-English preferred language (aOR, 1.78; 95% CI, 1.18-2.79). Medicare insurance was significantly associated with having ACP (aOR for missing ACP, 0.63; 95% CI, 0.40-0.95). In this study, perioperative ACP was uncommon, particularly in men, individuals with a non-English preferred language, and those without Medicare insurance coverage. The perioperative setting may represent a missed opportunity for ACP for older surgical patients. When addressing ACP for surgical patients, particular attention should be paid to overcoming language-related disparities.

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions

BackgroundPhysician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions.MethodsThis study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed.ResultsThere were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient’s POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated “transport to hospital only if comfort needs cannot be met in current location”, 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose “Non-transport, Against Medical Advice”. The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing.ConclusionThe POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Advanced care planning (ACP) intervention for older patient with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS).

e19004 Background: The Serious Illness Care Program (SICP) is an evidence-based intervention that promotes ACP for patients with advanced cancer. As part of a study to adapt the SICP for older patients with AML and MDS, we identified clinician and patient reported barriers to ACP for this population, and their suggestions to improve ACP. Methods: In single-center qualitative study, we conducted semi-structured interviews with 14 oncology clinicians and 7 patients with AML or MDS. Interviews were audio-recorded and transcribed. Two investigators independently coded all transcripts using MAXQDA and resolved discrepancies through iteration. Direct content analysis techniques were used to focus on ACP barriers and suggestions. Results: Mean ages of clinicians and patients were 45 and 73, respectively. Majority of patients were not familiar with ACP. All patients had a healthcare proxy. Half of patients were familiar with a Medical Orders for Life-Sustaining Treatment (MOLST) form. Two major themes identified by clinicians and patients were: 1) Discomfort and logistics as ACP barriers (Table) and 2) ACP visit structure. Both clinicians and patients suggested the importance of earlier ACP visits. Clinicians suggested separate outpatient ACP visits, while patients suggested ACP after in-depth treatment discussion. Conclusions: Discomfort and logistics were identified as major barriers to ACP. Initiating ACP earlier was identified as a possible solution by clinicians and patients. Feedback obtained will be used to adapt the SICP to be delivered via Telehealth in a single arm pilot study.[Table: see text]

Nurse practitioners in home-based prepalliative care demonstrate an innovative, value-based approach to end-of-life care planning.

Nurse practitioners (NPs) demonstrate value-based, home-based primary health care (HBPC) to home-bound patients with high disease burden at reduced cost. The research questions were as follows: (a) Does patient-centered, prepalliative care delivered by HBPC NPs decrease number of hospitalizations and emergency department (ED) visits and increase patient satisfaction? and (b) What are the criteria for patients to receive end-of-life (EOL) discussions by NPs? This was a quasi-experimental, retrospective two-group design with a convenience sample of 233 HBPC patients from an academic clinical partnership compared with 234 clinic patients matched on age and Charlson Comorbidity Index (CCI) score over 4 years. Measures included signed advanced directives (ADRs), medical orders of life-sustaining treatment (MOLST) forms, number and length of home visits, hospitalizations, and ED visits after diagnosis. Chi-square analyses and general linear models using a Poisson distribution were conducted. Home-based primary health care patients had higher disease burden, statistically higher CCI scores, and signed ADR and MOLST agreements more often than clinic patients with significantly fewer hospitalizations and ED visits, and longer visits with providers. Patients receiving HBPC for prepalliative, EOL illness benefit from more time to discuss the difficult factors surrounding access to care for those with life-threatening illnesses. Recipients of prepalliative HBPC by NPs could require fewer provider visits, hospitalizations and ED visits, patient satisfaction, and a potential decrease in health care spending at EOL.

Outpatient Palliative Care for Noncancer Illnesses: One Program's Experience with Implementation, Impact, and Lessons Learned.

Background: Despite substantial palliative care (PC) needs in people with serious illnesses other than cancer, outpatient PC is less available to these populations. Objectives: Describe the experience, impact, and lessons learned from implementing an outpatient PC service (OPCS) for people with noncancer illnesses. Design: Observational cohort study. Setting/Subjects: Patients seen by an OPCS at a United States academic medical center October 2, 2017-March 31, 2021. Measurements: Patient demographics and clinical characteristics, care processes, rates of advance care planning (ACP), and health care utilization. Results: During the study period, 736 patients were seen. Mean age was 66.7 years, 47.7% were women, and 61.4% were White. Nearly half (44.9%) had a neurologic diagnosis, 19.2% pulmonary, and 11.0% cardiovascular. Patients were most often referred for symptoms other than pain (62.2%), ACP (60.2%), and support for patient/family (48.2%). Three-quarters (74.1%) of visits occurred by video. A PC physician, nurse, social worker, and spiritual care provider addressed nonpain symptoms (for 79.2%), family caregiver needs (70.0%), psychosocial distress (69.9%), ACP (68.8%), care coordination (66.8%), pain (38.2%), and spiritual concerns (27.8%). Rates of advance directives increased from 24.6% to 31.8% (p < 0.001) and Physician Orders for Life-Sustaining Treatment forms from 15.6% to 27.3% (p < 0.001). Of 214 patients who died, 61.7% used hospice, with median hospice length-of-stay >30 days. Comparing the six months before initiating PC to the six months after, hospitalizations decreased by 31.3% (p = 0.001) and hospital days decreased by 29.8% (p = 0.02). Conclusions: Outpatient PC for people with noncancer illnesses is feasible, addresses needs in multiple domains, and is associated with increased rates of ACP and decreased health care utilization. Controlled studies are warranted.

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 figures, 8 tables, and 58 references Keywords: Advance directives, power of attorney in health care, do not resuscitate order, decision-making, end-of-life, critical care

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 figures, 8 tables, and 58 references Keywords: Advance directives, power of attorney in health care, do not resuscitate order, decision-making, end-of-life, critical care

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 figures, 8 tables, and 58 references Keywords: Advance directives, power of attorney in health care, do not resuscitate order, decision-making, end-of-life, critical care

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 figures, 8 tables, and 58 references Keywords: Advance directives, power of attorney in health care, do not resuscitate order, decision-making, end-of-life, critical care

Emergency medical service interpretation of Physician Orders for Life-Sustaining Treatment (POLST) in cardiopulmonary arrest.

ObjectivePhysician Orders for Life‐Sustaining Treatment (POLST) forms exist in some form in all 50 states. This study evaluates emergency medical service (EMS) practitioners interpretation of the POLST in cardiopulmonary arrest.MethodsThis study used a prospective convenience sample of California Bay Area EMS practitioners who reviewed 6 fictional scenarios of patients in cardiopulmonary arrest and accompanying California POLST forms. Based on the cases and POLST, EMS practitioners identified patient preference for “attempt resuscitation,” “do not attempt resuscitation/DNR,” or “unsure” and subsequently selected medical interventions (ie, chest compressions, defibrillation, and so on). They also rated their confidence in POLST use and interpretation.ResultsIn scenarios of cardiopulmonary arrest and POLST that indicated do not resuscitate (DNR)/do not attempt resuscitation (DNAR) and full treatment, only 45%–65% of EMS practitioners correctly identified the patient as DNR/DNAR. EMS practitioners were more likely to interpret the POLST correctly in scenarios where patients were DNR/DNAR but indicated selective treatment (86%; 168/196) or comfort‐focused treatment (86%; 169/196). In cardiopulmonary arrest scenarios where the patient was correctly identified as DNR/DNAR, EMS practitioners frequently selected defibrillation, advanced airway, or epinephrine as appropriate treatment. For all 6 scenarios, there was no statistical difference in response selection with level of training (emergency medical technician/paramedics) or type of EMS personnel (fire based/private).ConclusionThe POLST is a powerful tool to convey medical treatment preferences; however, there is significant variation in the interpretation and application by EMS practitioners. To improve the POLST effectiveness, the authors suggest more EMS input into POLST development, concise language that defines resuscitation, and more EMS education about clinical application.

Randomized Trial of a Palliative Care Intervention to Improve End-of-Life Care Discussions in Patients With Metastatic Breast Cancer.

Studies show that early, integrated palliative care (PC) improves quality of life (QoL) and end-of-life (EoL) care for patients with poor-prognosis cancers. However, the optimal strategy for delivering PC for those with advanced cancers who have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a PC intervention on the documentation of EoL care discussions, patient-reported outcomes, and hospice utilization in this population. Patients with MBC and clinical indicators of poor prognosis (n=120) were randomly assigned to receive an outpatient PC intervention (n=61) or usual care (n=59) between May 2, 2016, and December 26, 2018, at an academic cancer center. The intervention entailed 5 structured PC visits focusing on symptom management, coping, prognostic awareness, decision-making, and EoL planning. The primary outcome was documentation of EoL care discussions in the electronic health record (EHR). Secondary outcomes included patient-report of discussions with clinicians about EoL care, QoL, and mood symptoms at 6, 12, 18, and 24 weeks after baseline and hospice utilization. The rate of EoL care discussions documented in the EHR was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%; P=.006), including a higher completion rate of a Medical Orders for Life-Sustaining Treatment form (39.3% vs 13.6%; P=.002). Intervention patients were also more likely to report discussing their EoL care wishes with their doctor (odds ratio [OR], 3.10; 95% CI, 1.21-7.94; P=.019) and to receive hospice services (OR, 4.03; 95% CI, 1.10-14.73; P=.035) compared with usual care patients. Study groups did not differ in patient-reported QoL or mood symptoms. This PC intervention significantly improved rates of discussion and documentation regarding EoL care and delivery of hospice services among patients with MBC, demonstrating that PC can be tailored to address the supportive care needs of patients with longer disease trajectories. ClinicalTrials.gov identifier: NCT02730858.

Discussing patient preferences for levels of life-sustaining treatment: development and pilot testing of a Danish POLST form

BackgroundMedically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients’ preferences for levels of life-sustaining treatment are known and documented.MethodsThe study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners’ clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient’s values and preferences. Family members and/or nursing staff could participate. Participants’ assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation.ResultsIn total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future.ConclusionThe Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients’ preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study.

Are Young Adults Ready to Complete Advance Directives?

The dual objective of this study is to examine the perspectives of young adults toward advance directives (ADs) and their preferences related to life-sustaining treatment and care options. Participants include graduate students (n = 30) attending a university in New York State. Data were collected using a structured survey questionnaire and Medical Orders for Life-Sustaining Treatment (MOLST) form. Bivariate summary statistics were performed to address the study aims. The mean age of study participants was 24 years, 60% were female, 60% white, and 27% Black. Most (87%) participants reported being comfortable discussing death and end-of-life care and preferring to make their own decisions. Under the circumstance of no pulse and/or not breathing, 87% want CPR. With a pulse and respiration, 96% want artificially administered fluids and nutrition, 90% want a trial period of intubation and/or mechanical ventilation, 67% want to be sent to a hospital, 67% want antibiotics, and 53% want no limitations on medical intervention. Our findings extend upon previous research by quantifying young adults' specific beliefs, experiences, and preferences regarding advance directives and life-sustaining interventions. Young adults in our study preferred maximum medical interventions for life-sustaining treatment and care. Given the troubling trends in unintended injury (eg, car crashes and drug overdose) as the leading cause of death among young adults, they should be given an opportunity to understand the options and treatments available and should be encouraged to complete an AD.

Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned.

Palliative care (PC) is recommended for people with amyotrophic lateral sclerosis (ALS), but there is scant literature about how to best provide this care. We describe the structure and impact of a pilot program that integrates longitudinal, interdisciplinary PC into the care of patients with ALS. Observational cohort study of patients with ALS referred to outpatient PC and seen for at least 3 PC visits October 2017-July 2020. Fifty-five patients met the inclusion criteria. Three-quarters (74.5%) were Caucasian, and 78.2% spoke English. Patients were referred for advance care planning (58.2%), support for patient/family (52.7%), and symptoms other than pain (50.9%). Patients had a mean of 5 scheduled PC visits, the majority occurred by video. A PC physician, nurse, social worker, and chaplain addressed pain (for 43.6% of patients), nonpain symptoms (94.5%), psychosocial distress (78.2%), spiritual concerns (29.1%), care planning (96.4%), and supported family caregivers (96.4%). With PC, the rate of completion of advance directives increased from 16.4% to 36.4% (p = 0.001) and Physician Orders for Life-Sustaining Treatment forms from 10.9% to 63.6% (p < 0.001). Of the 27 patients who died, 77.8% used hospice, typically for more than 30 days. Eleven patients obtained aid-in-dying prescriptions, and 8 took these medications, accounting for 29.6% of the deaths. Integrating longitudinal, interdisciplinary PC into the care of patients with ALS is feasible, addresses needs in multiple domains, and is associated with increased rates of advance care planning. Controlled studies are needed to further elucidate the impact of PC on patients with ALS, their families, and clinicians.

Development of a Palliative Telehealth Pilot to Meet the Needs of the Nursing Home Population.

Many older adults will spend their final days in a skilled nursing facility because of multiple complex conditions. Patients with unclear goals of care are at higher risk of rehospitalization and burdensome care at end of life. Palliative care has been shown to improve outcomes for this patient population; however, access is limited because of the small number of boarded specialists nationwide. Telehealth offers the ability to expand the reach of palliative care to both underserved geographies and community settings. This quality improvement pilot project details the development and implementation of a telehealth palliative care program available to nursing home residents. Eight nursing homes, in the New England region of the United States, participated in the 4-month pilot. The palliative telehealth program offered real-time access to a palliative care specialist able to provide symptom management, goals-of-care discussions, and Medical Orders for Life-Sustaining Treatment completion. The pilot shows promising outcomes including code status change, Medical Order for Life-Sustaining Treatment form completion, and reduced hospitalizations supporting the benefit of comprehensive goals-of-care discussions for frail older adults living in a nursing home. As health care moves into the digital age, telemedicine plays a large role in the delivery of essential patient care. Provision of palliative specialists by telehealth allows the opportunity to address the unmet needs of this frail population.