Physician Orders For Life-Sustaining Treatment Orders Research Articles

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

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. 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. 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. 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.

Use of a State Registry to Compare Practices of Physicians and Nurse Practitioners in Completing Physician Orders for Life-Sustaining Treatment Forms.

Background: Understanding the role of nonphysicians in Physician Orders for Life-Sustaining Treatment (POLST) completion is limited. Objectives: To examine the role that nurse practitioners (NPs) play in POLST completion and differences between NPs and physicians in POLST orders. Design: Retrospective observational study. Setting/Subjects: A total of 3829 POLST forms submitted to the West Virginia (WV) e-Directive Registry between July 1, 2018 and June 30, 2019, which was completed by 98 NPs and 511 physicians. Measurements: POLST forms completed and orders in POLST Section A and Section B by all physicians and NPs according to practice (primary care, palliative care, hospital, and nursing home) and by palliative care physicians and NPs only. Results: NPs completed almost twice as many forms on average as physicians (9.54 ± 20.82 vs. 5.66 ± 17.18, p = 0.0064). NPs constituted 16.10% (98/609) of the clinicians writing POLST forms but completed 24.40% (935/3829) of the forms (p < 0.001). Compared with physicians' orders, a greater percentage of NP's orders was for do-not-resuscitate in Section A (87.20% vs. 72.60%, p < 0.001) and comfort measures in Section B (42.90% vs. 33.10%, p < 0.001). There was a greater percentage of NPs in palliative care practice than physicians (23.50% vs. 6.07%, p < 0.001), and palliative care NPs completed 64.20% (600/935) of the forms submitted by NPs compared with palliative care physicians who completed 17.90% (517/2894) of the forms submitted by physicians (p < 0.001). Conclusions: In WV, physician and NP POLST completion differs based on practice. NPs completed significantly more POLST forms on average and more often ordered comfort measures. NPs can play a significant role in POLST completion.

Conflicting Orders in Physician Orders for Life-Sustaining Treatment Forms.

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. Retrospective cohort study. Large academic health system. A total of 3,123 POLST users with chronic life-limiting illness who died between 2010 and 2015 (mean age = 69.7 years). 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. 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). 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.

Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life

Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

The Pearls of Physician Orders for Life Sustaining Treatment (POLST): Translating Patient Decisions into Treatment Orders

Since the Physician Orders for Life Sustaining Treatment (POLST) Paradigm began in 1991, POLST has become utilized throughout the United States. POLST includes the national POLST Paradigm as well as state and regional programs and their specific POLST orders. Yet many nurses may not have received the education needed for POLST implementation. This article seeks to honor individual preferences through advance care planning (ACP) by providing an understanding of POLST, which documents individual treatment wishes as medical orders. In the article the authors discuss advance care planning, advance directives, changes in patient status, and the inception and description of POLST. They distinguish POLST from DNR orders, compare POLST to advance directives, and describe the roles of registered and advanced practice nurses. Additionally, they consider studies that have endorsed the POLST paradigm, and share POLST paradigm pearls as well as possible paradigm pitfalls.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records.

ObjectiveThe aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders.MethodsWe identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA.ResultsOf 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of “4” (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients.ConclusionsDo-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.

The Quality of Physician Orders for Life-Sustaining Treatment Decisions: A Pilot Study

Physician Orders for Life-Sustaining Treatment (POLST) forms are used to document patient treatment preferences as medical orders. Prior research demonstrates that use of POLST alters medical treatments in a way that is consistent with the POLST orders. However, there are minimal data about the quality of POLST decisions, including whether they reflect the current preferences of well-informed patients. Evaluate the quality of POLST decisions. Chart abstraction; interviews. Nursing home residents and healthcare agents of incapacitated nursing home residents (n = 28). Characteristics of the POLST conversation were assessed. Brief vignettes were used to assess knowledge about how POLST orders guide medical treatment. Current treatment preferences were elicited and compared with the patient's POLST orders to assess discordance. A majority (59%) of participants recognized the POLST form. Participants were generally accurate in their knowledge of how POLST orders guide treatment concerning cardiopulmonary resuscitation (CPR) (68%), antibiotics (74%), and artificial nutrition (79%), but less so for medical interventions (50%). Current treatment preferences were initially discordant with one or more POLST orders for 64% (18/28) of participants, but half of these discordances were resolved with further discussion (e.g., participant agreed with the existing order). Discordance by treatment decision was as follows: CPR (7%), level of medical intervention (18%), antibiotics (21%), and artificial nutrition (11%). Discordance between current preferences and POLST orders is complex. Interventions are needed to support high-quality POLST decisions that are informed and concordant with current preferences.

Timing of POLST Form Completion by Cause of Death

ContextThe physician orders for life-sustaining treatment (POLST) paradigm allows health care professionals to document the treatment preferences of patients with advanced illness or frailty as portable and actionable medical orders. National standards encourage offering POLST orders to patients for whom clinicians would not be surprised if they died in the next year. ObjectivesTo determine the influence of cause of death on the timing of POLST form completion and on changes to POLST orders as death approaches. MethodsThis was a cohort study of 18,285 Oregon POLST Registry decedents who died in 2010–2011 matched to Oregon death certificates. ResultsThe median interval between POLST completion and death was 6.4 weeks. Those dying of cancer had forms completed nearer death (median 5.1 weeks) than those with organ failure (10.6 weeks) or dementia (14.5 weeks; P < 0.001). More than 90% of final POLST forms indicated orders for no resuscitation and 65.1% listed orders for comfort measures only. Eleven percent of the sample had multiple registered forms during the two years preceding their death, with the form completed nearest to death more likely than earlier forms to have orders for no resuscitation and comfort measures only, although some later forms did have orders for more treatment. ConclusionMore than half of POLST forms were completed in the final two months of life. Cause of death influenced when POLST forms were completed. POLST forms changed in the two years preceding death, more frequently recording fewer life-sustaining treatment orders than the earlier form(s).

Association Between Physician Orders for Life‐Sustaining Treatment for Scope of Treatment and In‐Hospital Death in Oregon

To examine the relationship between Physician Orders for Life-Sustaining Treatment (POLST) for Scope of Treatment and setting of care at time of death. Cross-sectional. Oregon in 2010 and 2011. People who died of natural causes. Oregon death records containing cause and location of death were matched with POLST orders for people with a POLST form in the Oregon POLST registry. Logistic regression was used to measure the association between POLST orders and location of death. Of 58,000 decedents, 17,902 (30.9%) had a POLST form in the registry. Their orders for Scope of Treatment were comfort measure only, 11,836 (66.1%); limited interventions, 4,787 (26.7%); and full treatment, 1,153 (6.4%). Comfort measures only (CMO) orders advise avoiding hospitalization unless comfort cannot be achieved in the current setting; 6.4% of participants with POLST CMO orders died in the hospital, compared with 44.2% of those with orders for full treatment and 34.2% for those with no POLST form in the registry. In the logistic regression, the odds of dying in the hospital of those with an order for limited interventions was 3.97 times as great (95% CI = 3.59-4.39) as of those with a CMO order, and the odds of those with an order for full treatment was 9.66 times as great (95% CI = 8.39-11.13). The association with numbers of deaths in the hospital suggests that end-of-life preferences of people who wish to avoid hospitalization as documented in POLST orders are honored.

Use of the Physician Orders for Life-Sustaining Treatment Program for Patients Being Discharged from the Hospital to the Nursing Facility

The Physician Orders for Life-Sustaining Treatment (POLST) documents patient preferences as medical orders that transfer across settings with patients. The objectives were to pilot test methods and gather preliminary data about POLST including (1) use at time of hospital discharge, (2) transfers across settings, and (3) consistency with prior decisions. Descriptive with chart abstraction and interviews. Participants were hospitalized patients discharged to a nursing facility and/or their surrogates in La Crosse County, Wisconsin. POLST forms were abstracted from hospital records for 151 patients. Hospital and nursing facility chart data were abstracted and interviews were conducted with an additional 39 patients/surrogates. Overall, 176 patients had valid POLST forms at the time of discharge from the hospital, and many (38.6%; 68/176) only documented code status. When the whole POLST was completed, orders were more often marked as based on a discussion with the patient and/or surrogate than when the form was used just for code status (95.1% versus 13.8%, p<.001). In the follow-up and interview sample, a majority (90.6%; 29/32) of POLST forms written in the hospital were unchanged up to three weeks after nursing facility admission. Most (71.9%; 23/32) appeared consistent with patient or surrogate recall of prior treatment decisions. POLST forms generated in the hospital do transfer with patients across settings, but are often used only to document code status. POLST orders appeared largely consistent with prior treatment decisions. Further research is needed to assess the quality of POLST decisions.

Concordance of Out-of-Hospital and Emergency Department Cardiac Arrest Resuscitation With Documented End-of-Life Choices in Oregon

Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest. This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED. There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated. In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregon's POLST system to other methods of end-of-life order documentation.

The Oregon Physician Orders for Life-Sustaining Treatment Registry: A Preliminary Study of Emergency Medical Services Utilization

BackgroundThe Physician Orders for Life-Sustaining Treatment (POLST) form translates patient treatment preferences into medical orders. The Oregon POLST Registry provides emergency personnel 24-h access to POLST forms. ObjectiveTo determine if Emergency Medical Technicians (EMTs) can use the Oregon POLST Registry to honor patient preferences. MethodsTwo telephone surveys were developed: one for the EMT who made a call to the Registry and one for the patient or the surrogate. The EMT survey was designed to determine if the POLST form accessed through the Registry changed the care of the patient. The patient/surrogate survey was designed to determine if the care provided matched the preferences on the POLST. When feasible, the Emergency Medical Services (EMS) record was reviewed to determine whether or not treatment was provided. ResultsDuring the study period there were 34 EMS calls with matches to patients' POLST forms, and 23 interviews were completed with EMS callers, for a response rate of 68%. In seven cases (30%) the patient was in cardiopulmonary arrest; one patient had a respiratory arrest with a pulse. Eight respondents (35%) reported that the patient was conscious and apparently able to make decisions about preferences. For 10 cases (44%) the POLST orders changed treatment, and in six instances (26%) they affected the decision to transport the patient. For the 10/11 patients or surrogates interviewed, the care reportedly matched their wishes. ConclusionThis small study suggests that an electronic registry of POLST forms can be used by EMTs to enhance their ability to locate and honor patient preferences regarding life-sustaining treatments.

Implementation of Physician Orders for Life Sustaining Treatment in Nursing Homes in California: Evaluation of a Novel Statewide Dissemination Mechanism

BACKGROUNDImplementing Physician Orders for Life Sustaining Treatment (POLST) forms aims to improve communication of life-sustaining treatment preferences across care venues. California enabled this clinical tool in 2009, and a novel intervention of community coalitions was undertaken to advance POLST in localities around the state. Coalitions engaged facilities, including nursing homes (NHs), to foster POLST adoption. Eighteen months after introduction of POLST, we studied POLST implementation in California NHs.METHODSNHs randomly selected in coalition and non-coalition areas were mailed surveys about POLST preparation and use in 2010. Coalitions identified which NHs they worked with.RESULTSOf 546 NHs surveyed, 143 (52 %) in coalition areas and 141 (52 %) in non-coalition areas responded. In 82 % of responding NHs, staff received POLST education and 59 % of NHs reported having a formal policy on handling POLST. Two-thirds of NHs had admitted a resident with a POLST, and 15 % of newly admitted residents over the past month had a POLST (range 0–100 %). Eighty-one percent of NHs had completed a POLST with a resident. Fifty-four percent of residents were estimated to have a POLST (range 0–100 %) (coalition area NHs 60 % vs. non- coalition area NHs 48 %, p = 0.02). Within coalition areas, NHs that had worked with coalitions were more likely to have completed a POLST with a resident after admission than NHs that had not worked with coalitions. Few NHs (7 %) reported difficulty following POLST orders, but 38 % noted difficulty involving physicians in POLST completion.CONCLUSIONLess than 2 years after introduction, many California nursing homes report using POLST, although some NHs reported no experience. A novel community coalition intervention facilitated POLST implementation.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-012-2178-2) contains supplementary material, which is available to authorized users.

The POLST Program: A Retrospective Review of the Demographics of Use and Outcomes in One Community Where Advance Directives Are Prevalent

Determine the use and utility of the Physician Orders for Life-Sustaining Treatment (POLST) program in a community where powers of attorney for health care (POAHCs) are prevalent. A retrospective review of medical record and death certificate data of 400 adults who died between September 1, 2007, and March 31, 2008, in the La Crosse County, Wisconsin community. Demographic and cause-of-death data were collected from death certificates. Information about POAHC, POLST forms, and medical treatments provided in the last 30 days of life were abstracted from decedents' medical records. Sixty-seven percent of decedents had a POLST form, whereas 22% had POAHC alone. In comparison with decedents with POAHC alone, decedents with a POLST form were significantly older (83 versus 77 years, p<0.001), more likely to die in a nursing home than in a hospital (p<0.001), and more likely to die from a terminal or chronic illnesses (97%). Decedents with POLST orders for higher levels of medical treatment received more treatment, and in only two cases was there evidence that treatment was discrepant with POLST orders. In 31% of all POLST forms, the person appointed in the POAHC consented to the POLST orders. POLST can be a highly effective program to ensure that patient preferences are known and honored in all settings. POAHCs are valuable because they identify appropriate surrogates when patients are incapacitated.

The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form

To evaluate the consistency between treatments provided and Physician Orders for Life-Sustaining Treatment (POLST) orders. Retrospective chart abstraction. Stratified, random sample of 90 nursing facilities in Oregon, Wisconsin, and West Virginia. Eight hundred seventy living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Chart data about POLST form orders and related treatments over a 60-day period were abstracted. Decision rules were created to determine whether the rationale for each treatment was consistent with POLST orders. Most residents (85.2%) had the same POLST form in place during the review period. A majority of treatments provided to residents with orders for comfort measures only (74.3%) and limited antibiotics (83.3%) were consistent with POLST orders because they were primarily comfort focused rather than life-prolonging, but antibiotics were provided to 32.1% of residents with orders for no antibiotics. Overall consistency rates between treatments and POLST orders were high for resuscitation (98%), medical interventions (91.1%), and antibiotics (92.9%) and modest for feeding tubes (63.6%). In all, POLST orders were consistent with treatments provided 94.0% of the time. With the exception of feeding tubes and antibiotic use in residents with orders for no antibiotics, the use of medical treatments was nearly always consistent with POLST orders to provide or withhold life-sustaining interventions. The POLST program is a useful tool for ensuring that the treatment preferences of nursing facility residents are honored.

A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life‐Sustaining Treatment Program

To evaluate the relationship between two methods to communicate treatment preferences (Physician Orders for Life-Sustaining Treatment (POLST) program vs traditional practices) and documentation of life-sustaining treatment orders, symptom assessment and management, and use of life-sustaining treatments. Retrospective observational cohort study conducted between June 2006 and April 2007. A stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia. One thousand seven hundred eleven living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Life-sustaining treatment orders; pain, shortness of breath, and related treatments over a 7-day period; and use of life-sustaining treatments over a 60-day period. Residents with POLST forms were more likely to have orders about life-sustaining treatment preferences beyond cardiopulmonary resuscitation than residents without (98.0% vs 16.1%, P<.001). There were no differences between residents with and without POLST forms in symptom assessment or management. Residents with POLST forms indicating orders for comfort measures only were less likely to receive medical interventions (e.g., hospitalization) than residents with POLST full treatment orders (P=.004), residents with traditional do-not-resuscitate orders (P<.001), or residents with traditional full code orders (P<.001). Residents with POLST forms were more likely to have treatment preferences documented as medical orders than those who did not, but there were no differences in symptom management or assessment. POLST orders restricting medical interventions were associated with less use of life-sustaining treatments. Findings suggest that the POLST program offers significant advantages over traditional methods to communicate preferences about life-sustaining treatments.