Physician Orders For Life-Sustaining Treatment Research Articles

Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery

Major vascular surgery, including open aortic procedures, is associated with having a 30-day mortality rate greater than 6% and a perioperative complication rate greater than 50%. Published literature suggests that patients undergoing high-risk procedures benefit from having a care plan in place to not only maximize quality of life but also to ensure medical interventions align with care goals. Currently, there is a paucity of published data on the prevalence of goals of care conversations, advance care planning documentation, and palliative care evaluations in patients undergoing high-risk vascular operations. A retrospective chart review of all patients who underwent open aortic surgery at a tertiary care academic medical center from July 2014 to March 2023 was performed. Patient demographics, comorbidities, type and timing of advanced care planning (ACP), palliative care evaluations, and clinical outcomes during the periprocedural period were recorded. For patients who died during the study period, the use of palliative care prior to death were noted. Patients who received ACP or palliative care were compared with those who did not. The cohort consisted of 192 patients who underwent major open aortic surgery. The mean age was 63 years (SD 12.3) and the majority of patients were male (73.4%) and white (64.1%). Thirty-nine (20.6%) operations were classified as emergent. At the time of their operation, 16.7% (n=32) of patients had an ACP document on file. Of the 38 documents on file, most were durable power of attorney (DPOA) (86.8%) documents while a smaller percentage were physician orders for life-sustaining treatment (POLST) (13.2%). There were no patients with Do Not Resuscitate and/or Intubate (DNR/DNI), living will, or organ/tissue donation orders noted in their chart prior to surgery. One percent (n=2) of patients had a palliative evaluation prior to their operation. During the perioperative period, an additional 2 (1%) of patients had advanced care planning documentation and 7 (3.7%) of patients underwent palliative care evaluation. Fifteen percent of patients (n=28) died during the perioperative period and an additional 21 patients died by the end of the study period for a total mortality of 25.2% in the study population. Among patients that died during the perioperative period, 28.6% (n=8 out of 28) received palliative care. Overall, 28.6% of all study patients that died (n=14 out of 49) received a palliative care evaluation prior to or during their terminal hospitalization. Patients who had ACP documents or who received palliative care consultations prior to surgery were older (p=0.01), more likely to be on Medicare or Medicaid (p=0.004), and more likely to have a history of solid organ malignancy (p=0.03). The median interval between surgery and receiving palliative care was 20 (IQR 3-71) days. The median interval between palliative care and death was 5 (IQR 2-13) days. Patients who utilized ACP or PC were more likely to die at home (p=0.05). Despite a high mortality and morbidity rate, ACP documentation is poor for patients undergoing major open aortic surgery. Palliative care interventions tend to be performed closer to the end of life, suggesting a missed opportunity to define goals of care.

The Progression of End-of-Life Wishes and Concordance with End-of-Life Care: An Update.

Importance: Concordance between physician orders for life-sustaining treatment (POLST) preferences and treatment at end-of-life is an important outcome measure of providing patient-centered care. Objectives: We determine whether the COVID pandemic affected clinician ability to provide goal concordant care and replicate our previous report on care concordance and change in patient preferences over time with a larger sample size. We also investigate the quality of POLST completion to determine the number of documents completed with an advance care planning (ACP) conversation or a decision maker present. Methods: Chart abstraction via structured questionnaire of 796 randomly selected patients who died in 2020 with a POLST on file. Results: We found 99% concordance in the last setting of death between a patient's POLST preferences and the care they received. We confirm our previous finding that patients' wishes shift towards a preference for lower treatment intensity at end-of-life. We found that 82% of POLSTs were created in the context of an ACP conversation, 77% with a decision maker present. Conclusion: High levels of goal concordant care were maintained during the pandemic. Because patient wishes evolve over time, clinicians should be trained and supported to revisit care preferences across the illness trajectory.

Nurses' engagement in advance care planning practices: A descriptive cross-sectional study.

To describe and compare nurses' awareness of, attitudes toward, and participation in advance care planning, as well as related facilitators and challenges, in four types of healthcare settings. A cross-sectional descriptive study. Four hundred and ninety-eight registered nurses from tertiary, secondary and primary healthcare institutions, along with long-term care centres in South Korea, participated in an investigator-developed online survey. The collected data were analysed using descriptive statistics, chi-squared test, one-way ANOVA, and binary logistic regression. Participants were on average 30.6 ± 7.3 years old, mostly female (95.4%), employed as staff nurses (95.4%), held bachelor's degrees or higher (84.1%), and had worked for less than 5 years at their current institutions (69.7%). Overall, 49% of the participants were familiar with advance care planning. While most participants supported nurse involvement in advance care planning with patients and surrogates, fewer were willing to engage or recommend it. Less than half were actively engaged in advance care planning practices. A notable challenge was the lack of time due to excessive workload. Compared to those from tertiary healthcare institutions, participants from secondary and primary healthcare institutions and long-term care centres were less likely to be aware of advance care planning. Participants from secondary and primary healthcare institutions had lower odds of checking for the presence of advance directives and the physician orders for life-sustaining treatment. Nurses demonstrated low awareness and participation in advance care planning. Nurses' insufficient time and competency to conduct advance care planning in their practice should be addressed. Educational programs, initiatives (e.g. guidelines, position statements) and legal and policy-level efforts (e.g. nurse staffing, role clarification, reimbursement) are crucial to incorporate advance care planning into routine nursing practice. What problem did the study address? Nurses play an important role in advance care planning; however, limited is understood about their readiness and involvement in such practices. What were the main findings? Nurses' awareness of advance care planning practices and their participation in such practices is low across care settings. Although nurses have a positive attitude toward advance care planning, there are challenges (e.g. insufficient time to conduct advance care planning discussions and lack of relevant knowledge and skills) that impede their participation in practice. Where and on whom will the research have an impact? This study may serve as a foundation for nursing societies in countries, where advance care planning is emerging, to discuss strategies to increase nurses' competency in advance care planning and promote their participation in the practice. The STROBE checklist was followed. No patient or public contribution.

Correlation of significant delays and ethnic disparities in the receipt of treatment, palliative care, and supportive care interventions in pancreatic adenocarcinoma.

e16355 Background: In patients with pancreatic adenocarcinoma (PDAC), immediate treatment initiation is preferred. Early palliative care initiation has also improved quality of life and symptom burden. However, the timing of real-world treatment and palliative care initiation and possible ethnic disparities are not well understood. The objective of this study was to evaluate the timing of care initiation in a mainly Hispanic population of PDAC patients. Methods: We conducted a retrospective cohort study that included patients diagnosed with PDAC from 2014 to 2023 at Loma Linda University Health (the only tertiary care center for two large Hispanic-majority counties with large rural populations). Data were obtained on the presence and timing of appropriate provider referrals, care establishment, treatment, advanced care planning, and hospital admissions. We used a Wilcoxon rank-sum test to compare Hispanic and non-Hispanic patients regarding the time to treatment initiation and palliative care initiation. Results: 263 PDAC patients were identified (mean age 66, 57% female, 47% Hispanic, 67% head tumor, 78% stage III/IV). After diagnosis, 93% of patients were referred to medical oncology, 82% to surgical oncology, 61% to palliative care, and 30% to genetic testing. An advanced directive or physician orders for life-sustaining treatment was completed for 24% of patients. The time to care initiation is as follows: a median of 23 days (IQR 14, 54) from diagnosis to the first medical oncology visit, 13 days (IQR 6, 37) to the first surgical oncology visit, 73 days (IQR 24, 132) to the first palliative care visit and 133 days (IQR 47, 329) to hospice referral. 64% of hospice referrals were placed within the last two weeks of life. Hispanic patients had a significantly longer time to treatment initiation (68 days vs. 48 days, p= 0.008) but similar times to palliative care initiation (73 vs 74 days, p= 0.64). Hispanics also had a lower rate of completing genetic testing (45% to 66%, p= 0.07). Conclusions: In our retrospective cohort study, significant delays in establishing care with oncology, palliative care, and hospice initiation in patients with PDAC were noted. Low rates of advanced care planning were also noted despite guideline recommendations for early-focused symptomatic interventions and advanced care planning. Hispanic patients had significantly longer time to treatment initiation and lower rates of genetic testing. These results indicate a need for improved targeted patient care navigation for multidisciplinary PDAC management, particularly in Hispanic patients.

Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care

ContextRecent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences. ObjectivesTo better understand decision-making regarding mechanical ventilation in people living with dementia. MethodsThis was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use. ResultsThe median age was 78 years (IQR 71–86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization. ConclusionFuture efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.

Characteristics and outcomes of patients with do-not-resuscitate and physician orders for life-sustaining treatment in a medical intensive care unit: a retrospective cohort study

BackgroundIn the intensive care unit (ICU), we may encounter patients who have completed a Do-Not-Resuscitate (DNR) or a Physician Orders to Stop Life-Sustaining Treatment (POLST) document. However, the characteristics of ICU patients who choose DNR/POLST are not well understood.MethodsWe retrospectively analyzed the electronic medical records of 577 patients admitted to a medical ICU from October 2019 to November 2020, focusing on the characteristics of patients according to whether they completed DNR/POLST documents. Patients were categorized into DNR/POLST group and no DNR/POLST group according to whether they completed DNR/POLST documents, and logistic regression analysis was used to evaluate factors influencing DNR/POLST document completion.ResultsA total of 577 patients were admitted to the ICU. Of these, 211 patients (36.6%) had DNR or POLST records. DNR and/or POLST were completed prior to ICU admission in 48 (22.7%) patients. The DNR/POLST group was older (72.9 ± 13.5 vs. 67.6 ± 13.8 years, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (26.1 ± 9.2 vs. 20.3 ± 7.7, p < 0.001) and clinical frailty scale (5.1 ± 1.4 vs. 4.4 ± 1.4, p < 0.001) than the other groups. Solid tumors, hematologic malignancies, and chronic lung disease were the most common comorbidities in the DNR/POLST groups. The DNR/POLST group had higher ICU and in-hospital mortality and more invasive treatments (arterial line, central line, renal replacement therapy, invasive mechanical ventilation) than the other groups. Body mass index, APAHCE II score, hematologic malignancy, DNR/POLST were factors associated with in-hospital mortality.ConclusionsAmong ICU patients, 36.6% had DNR or POLST orders and received more invasive treatments. This is contrary to the common belief that DNR/POLST patients would receive less invasive treatment and underscores the need to better understand and include end-of-life care as an important ongoing aspect of patient care, along with communication with patients and families.

연명의료결정법 대상 환자의 연명의료결정과 사망 전 의료이용에의 영향요인

This study embarks on a detailed cohort analysis to identify the factors influencing life-sustaining treatment (LST) decisions and healthcare usage before death. Utilizing multinomial logistic regression, it examines a diverse sample of 1,072 patients, categorized into three groups: self-determination, family determination, and DNR. The majority of the cohort, 49.4%, falls under the self-determination group, with a significant proportion of patients (92.8%) suffering from cancer. We find that the most common medical intervention in the week preceding death was blood transfusions, accounting for 49.2% of cases. The study reveals that the self-determination group experienced lower daily healthcare costs, higher hospice utilization rates, and longer intervals between physician orders for life-sustaining treatment(POLST) or DNR completion and death, compared to the other groups. Moreover, patients with stupor on admission were significantly more likely to be in the family determination group (36.225 times) or the DNR group (19.422 times) than in the self-determination group. Furthermore, the likelihood of ICU use was higher in the family determination (3.627 times) and DNR groups (4.137 times), with the application of mechanical ventilation being 2.372 times more common in the family determination group and 4.209 times in the DNR group. Lastly, cardiopulmonary resuscitation was 9.122 times more prevalent in the DNR group compared to the self-determination group. The study concludes that self-determination in LST can significantly reduce unnecessary healthcare utilization before death and promote hospice care utilization, underscoring the necessity of supporting patients in planning their end-of-life care, including decisions about LST.

Impact on End‐of‐life Planning of a Care Coordination Program for persons living with dementia

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) afflict over five million persons in the U.S., and persons living with dementia (PLWD) have been shown to receive poor quality care and have worse health outcomes compared to those without ADRD. We developed a population‐based dementia care management program to support the care of PWLD in a large U.S. healthcare system.MethodsIn a large multi‐specialty medical group practice, we identified patients enrolled in a value‐based insurance program (Medicare Advantage) using the EPIC electronic health record (EHR), and eligible patients were invited to enroll in the CARES dementia care program. Patients were eligible if they had an ICD‐10 diagnosis of ADRD in the EHR problem list and/or past medical history, or currently taking an FDA‐approved medication for ADRD. We additionally included patients with ADRD who have a primary care provider in the affiliated academic health system. During an in‐person intake visit, a study‐assigned nurse practitioner (NP) engaged in advance care planning discussion with patients and caregivers and completed advance directives (AD) and Physician Order for Life Sustaining Treatment (POLST). We assessed the rate of completion of the AD and POLST pre‐program and post‐enrollment.ResultsWe enrolled 195 patients in the CARES dementia care program. After enrollment, participants increased completion of advanced directives from 27.7% to 30.8% (p = 0.25) and the POLST from 13.3% to 23.1% (p = 0.006). Of the POLST forms completed, 70.7% indicated that the patient was ‘do not attempt resuscitation’ (DNAR) (65.2% of those who completed the POLST pre‐program, 77.8% for those who completed after enrollment, p = 0.19). Among those who completed the POLST, 55.0% indicated selective medical interventions (63.6% pre‐program, 47.1% post‐enrollment, p = 0.15), 40.0% wanted full medical interventions (31.8% pre‐program, 52.9% post‐enrollment, p = 0.10), and 5.0% wanted comfort‐focused interventions (4.5% pre‐program, 5.9% post‐enrollment, p = 0.43). Trial period of nutritional supports was indicated by 69.2% (72.7% pre‐program, 64.7% post‐enrollment, p = 0.28), while 28.2% wanted no artificial treatment (27.2% pre‐program, 29.4% post‐enrollment, p = 0.45), and 2.6% wanted long‐term nutritional support (0% pre‐program, 5.9% post‐enrollment, p = 0.13).ConclusionA dementia care coordination program shows signs of increased completion of end‐of‐life planning, with the majority choosing ‘do not attempt resuscitation’ (DNAR).

Antibiotics use patterns in end-of-life cancer patients and medical staff's perception of antimicrobial stewardship programs.

While most cancer patients with end-of-life (EOL) care receive antibiotic treatments, antibiotic use should be decided appropriately considering the benefits, side effects, resistance, and cost effects. Antimicrobial stewardship programs (ASP) are important for patients with EOL care, but there is limited study analyzing actual antibiotic use in EOL care and the perceptions of Korean medical staff. Electronic medical records of 149 deceased cancer patients hospitalized in the medical hospitalist units at Asan Medical Center in Seoul from May 2019 to September 2021 were reviewed. Basic information, antibiotic use, duration, and changes were investigated. We surveyed medical staff's perceptions of antibiotics in cancer patients with EOL. Of the 149 cancer patients with EOL care, 146 (98.0%) agreed with physician orders for life-sustaining treatment (POLST). In total, 143 (95.9%) received antibiotics, 110 (76.9%) received combination antibiotic treatment, and 116 (81.1%) were given antibiotics until the day of death. In a survey of 60 medical staff, 42 (70.0%) did not know about ASP, and 24 (40.0%) thought ASP was important in EOL care. Nineteen doctors (31.7%) discussed the use or discontinuation of antibiotics with patients or caregivers when writing POLST, but only 8 patients (5.6%) stopped antibiotics after POLST. Most cancer patients with EOL care continue to receive antibiotics until just before their death. A careful approach is needed, considering the benefits and side effects of antibiotic use, and the patient's right to self-decision. It is necessary to actively improve awareness of ASP and its importance for medical staff.

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

The Connecticut MOLST: Lessons for Policy and Practice

In accordance with national directives from POLST.org, Connecticut’s Department of Public Health formed a working group to review the literature and new directives for a Medical Orders for Life-Sustaining Treatment program in the state in 2013 that was signed into law in 2017. Five years later, many barriers have kept the program from becoming well-known and accessible to medical providers and the public. These policy lessons are important for the developing programs of other states to keep in mind as they further develop their own Medical Orders for Life-Sustaining Treatment (MOLST)/Physician Orders for Life-Sustaining Treatment (POLST) programs that ensure end-of-life wishes for life-sustaining treatments are honored on a form that is transferrable between institutions. Additionally, the goals of care conversation, teaching, and advocacy for better policies affecting end-of-life care remain critical skills for the nurse practitioner.

Changes over time in POLST use and content by race and ethnicity among California nursing home residents.

Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity. California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned. POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups. Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative.

Advance Care Planning Among Patients With Advanced Illness Presenting to the Emergency Department

BackgroundAdvance care planning (ACP) benefits emergency department (ED) patients with advanced illness. Although Medicare implemented physician reimbursement for ACP discussions in 2016, early studies found limited uptake. ObjectiveWe conducted a pilot study to assess ACP documentation and billing to inform the development of ED-based interventions to increase ACP. MethodsWe conducted a retrospective chart review to quantify the proportion of ED patients with advanced illness with Physician Orders for Life-Sustaining Treatment (POLST) or coding of ACP discussion in the medical record. We surveyed a subset of patients via phone to evaluate ACP participation. ResultsOf 186 patients included in the chart review, 68 (37%) had a POLST and none had ACP discussions billed. Of 50 patients surveyed, 18 (36%) recalled prior ACP discussions. ConclusionsGiven the low uptake of ACP discussions in ED patients with advanced illness, the ED may be an underused setting for interventions to increase ACP discussions and documentation.

Protecting seriously ill populations during pragmatic clinical trials.

Pragmatic clinical trials (PCTs) emphasize real-world effectiveness methodology to address the limitations of results from explanatory randomized clinical trials (RCTs), which often fail to translate to real-world medical practice. An inherent tension in the conduct of PCTs is that the research must impose a minimal burden on patients and health care institutions. PCTs prioritize outcome measures from existing data sources to minimize data collection burden; however, a lack of patient-reported outcomes may result in gaps in safety for vulnerable populations, such as those with serious illnesses. One proposed standard for judging the readiness of a study for a pragmatic trial is a ranking system that assigns PCTs a lower rank if they impose additional data collection burdens. However, this results in the wide use of measures of health care utilization and costs while patient experience measures, which could capture adverse unintended consequences, are omitted. In this article, we make the case for a risk-based approach to imposing additional data collection in PCTs to capture potential safety and patient experience outcomes, using examples from "real life" implemented interventions to improve end-of-life care through the Liverpool Pathway and through the implementation of Physician Orders for Life Sustaining Treatment (POLST) in Oregon.

Experience and perspectives of end-of-life care discussion and physician orders for life-sustaining treatment of Korea (POLST-K): a cross-sectional study

BackgroundThis study aimed to identify the healthcare providers’ experience and perspectives toward end-of-life care decisions focusing on end-of-life discussion and physician’s order of life-sustaining treatment documentation in Korea which are major parts of the Life-Sustaining Treatment Act.MethodsA cross-sectional survey was conducted using a questionnaire developed by the authors. A total of 474 subjects—94 attending physicians, 87 resident physicians, and 293 nurses—participated in the survey, and the data analysis was performed in terms of frequency, percentage, mean and standard deviation using the SPSS 24.0 program.ResultsStudy results showed that respondents were aware of terminal illness and physician’s order of life-sustaining treatment in Korea well enough except for some details. Physicians reported uncertainty in terminal state diagnosis and disease trajectory as the most challenging. Study participants regarded factors (related to relationships and communications) on the healthcare providers’ side as the major impediment to end-of-life discussion. Study respondents suggested that simplification of the process and more staff are required to facilitate end-of-life discussion and documentation.ConclusionBased on the study results, adequate education and training for better end-of-life discussion are required for future practice. Also, a simple and clear procedure for completing a physician’s order of life-sustaining treatment in Korea should be prepared and legal and ethical advice would be required. Since the enactment of the Life-Sustaining Treatment Act, several revisions already have been made including disease categories, thus continuous education to update and support clinicians is also called for.

Decision and Practice of End-of-Life Care in Lung Disease Patients with Physicians Orders for Life Sustaining Treatment.

The purpose of this study was to analyze end-of-life care practices in lung disease patients with physician orders for life-sustaining treatment (POLSTs). We retrospectively analyzed data from medical records regarding the end-of-life care practices of POLST decisions for patients with lung disease hospitalized at a tertiary hospital in Seoul, South Korea. Data were collected from January 1 to June 30, 2021. Of 300 total patients, 198 had lung cancer (66.0%) and 102 had non-malignant lung diseases (34.0%). A POLST was written for 187 patients (62.3%), and an advance directive was written for 20 patients (6.7%). Subsequent treatments were hemodialysis in 13 patients (4.3%), surgery in 3 patients (1.0%), and cardiopulmonary cerebral resuscitation in 1 patient (0.3%). Among cancer patients, chemotherapy was performed in 11 patients (3.7%), targeted therapy in 11 patients (3.7%), immunotherapy in 6 patients (2.0%), and radiation therapy in 13 patients (4.3%). Depending on the type of lung disease, types of treatment differed, including hemodialysis, ventilators, bilevel positive airway pressure, high-flow nasal cannulas, nebulizers, enteral nutrition, central line, inotropic agents, and opioids. Although the goals of hospice care are the same whether a patient has lung cancer or a non-malignant lung disease, because the characteristics of the respective diseases differ, end-of-life care practices and hospice approaches must be considered differently.

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...

Emergency medicine provider comfort with Physician Orders for Life Sustaining Treatment (POLST) advanced directive

Emergency departments (ED) across the United States see many patients with advanced disease nearing the end of life. ED providers make many important decisions that impact a patient’s hospital course, including resuscitation decisions. When patients’ preferences are not known, treatment in the ED frequently defaults to maximally aggressive care. The Physician Orders for Life Sustaining Treatment (POLST) form has been shown to lead to more goal-concordant care for these patients by providing detailed instructions regarding end-of-life interventions, made by the patient and/or medical decision maker.

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.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record.