Physician Orders For Life-Sustaining Treatment Research Articles

Outpatient palliative care at a tertiary cancer center: Perceptions, pathways, and pitfalls.

28 Background: To describe an outpatient palliative care program at a quaternary cancer center- Stanford Cancer Institute. Outpatient palliative care (PC) programs are still in their nascency. Best practices are still being developed and key performance metrics are being delineated. This is a description of Stanford Cancer Institute outpatient PC program. Methods: Observational study of the first six months of encounters to the outpatient PC program. Description of potential barriers to launch and growth, as well as description of resources required for continued success. Data evaluated included program volume, referral patterns, advance care planning, symptom assessment and team structure as collected by the clinical team. Results: Initial barriers to program initiation included lack of funding and infrastructure. Additional barriers included coordination between teams, flow of care (patients late for next appointments), and cultural perceptions of palliative care as equal to end of life care. There are 32 referring practitioners to the program. Over the first six months the outpatient PC program has seen growth with volume increasing from 10 consults per month to 26 consults per month for a total of 60 patients. At the time of initial consult, 11 of the 60 patients seen had an advance directive. Only 1 patient had a physician order for life sustaining treatment (POLST). Code status was documented in 21 of the 60 patients. Conclusions: Our program had multiple barriers to launch: perceptions that palliative care equaled end of life care, lack of infrastructure and funding, and difficulty with coordination between teams. With administrative support the program secured funding, developed infrastructure with the assistance of IT, Cancer Center administration, and Care Coordination. Consults now come from a wide range of providers. Based on preliminary data indicating a very low percentage of completion of these tasks by patients on initial consult there is need for outpatient palliative care for advance care planning. Future growth will include continued penetration of the cancer center, increasing volume of consults, and additional assessments of patient satisfaction, symptom improvement, and hospital utilization.

Assessment of end of life care (EOLC) outcomes in an Irish nursing home population using a modified version of the physician orders for life-sustaining treatment (POLST) tool

hysicians as the patients seen in clinical practice are not represenative of those on which treatments and interventions have been rialled, and we need to consider whether results from these trials re applicable to these patients. ethods.–Our aimwas to gaugewhether exclusion of older people as prevalent in Irish research proposals. We examined all clincal research submitted to the Research Ethics Committee (REC) ttached to Trinity CollegeDublin (TCD) from July 2008 to July 2011 nclusive, recording exclusion of patients based on an arbitrary pper age limit. esults.– Of the 226 relevant trials studied, 31 (13.7%) excluded articipants based solely their age. Twenty-two (9.8%) of the releant trialswere submittedbyGeriatricians, noneofwhich excluded atients based solely on age. Themean upper age limit used over all rials as a cut-off was 69.2 years. Additionally, most of the remainng research contained other exclusion criteria, especially based n cognitive function, which further limited participation of older eople. iscussion.– While a significant proportion of research we examned excluded older people arbitrarily, participation rates seem to e higher in this Irish centre than those seen internationally. Room or improvement remains however and there needs to be a prootion of greater awareness of the need for developing, testing nd licensing medicines so that it mirrors the consumer groups in hich they will be used. isclosure.– No significant relationships.

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.

CC1-03: Documentations of Advanced Health Care Directives in the Electronic Health Record: Where Are They?

Background/AimsAdvanced Care planning is becoming a major public health concern. The ambulatory care setting is a new frontier for delivery of palliative care services. Understanding patients? preferences and documenting them in an accessible location can facilitate honoring patients? wishes. However, physicians document Advanced Health Care Directives (AHCD) in various locations within EpicCare EHR, including progress notes, scanned documents, and the problem list. The aim of the study is to identify the locations of AHCD decision documentations in the EHR.MethodsExtensive search of AHCD terms in EPIC EHR, e.g., Physician Orders for Life-Sustaining Treatments (POLST), living will, and power of attorney, using 10 years of EHR data (2000?2010) in a large multispecialty ambulatory group practice in Northern California.ResultsA total of 76,887 patients had a documented AHCD decision. About 69% (53,270 of 76,887) had a decision in progress notes, 43% (33,265/76,887) in scanned documents, and 34% (26,146/76,887) in problem list. Overall, 36% of patients (28,045/76,887) had only progress note documentations, 25% (19,116/76,887) had only scanned documents, 16% (12,606/76,887) had both progress notes and problem list, and 12% (8,964/76,887) had documentation in all 3 locations. POLST documents made up 2% (853/37,706) of scanned documents. About 59% of patients (45,240/76,887) were >= 65 at the time of their first AHCD documentation. About 57% (44,067/76,887) were female. About 90% (5,689/6,347) of patients who died had their first AHCD decision documented within 5 years of their death. Documentation was updated nearing death - 90% (3,594/3,989) of patients who died and had more than one documented decision had their last decision documented within a year of death.DiscussionMost AHCD decisions are in progress notes in the EHR which can be difficult to access for busy physicians. Physicians? effort to elicit patient preferences for AHCD and subsequent decisions may be wasted if these decisions cannot be readily found in the EHR in actionable formats. Scanned documents containing signatures of the patient, surrogate, and if applicable, the physician, may be more actionable than text in progress notes without proper signatures and flagging. Standardizing the location of these important decisions needs to become a priority.

Validation of Physician Orders for Life‐Sustaining Treatment: Electronic Registry to Guide Emergency Care

Validation of Physician Orders for Life‐Sustaining Treatment: Electronic Registry to Guide Emergency Care

POLST: An improvement over traditional advance directives

Physician Orders for Life-Sustaining Treatment (POLST) is a process that translates a patient's goals for care at the end of life into medical orders that follow the patient across care settings. POLST overcomes the limitations of traditional advance directives. It enables physicians and other health care professionals, through a conversation with a patient or surrogate, to assess and convey the wishes of patients with serious life-limiting illness who may have a life expectancy of less than 1 year, or of anyone of advanced age interested in defining his or her wishes for end-of-life care.

California POLST education program

The California POLST (Physician Orders for Life-Sustaining Treatment) Education Program includes 7 integrated teaching modules designed to educate healthcare providers about POLST and the POLST Conversation. This comprehensive curriculum is...

Physician orders for life-sustaining treatment (POLST): unresolved conceptual and ethical questions

BackgroundIn the US, physician orders for life-sustaining treatment (POLSTs) are widely distributed. In Europe, on the other hand, emergency orders are still rarely reported from the ambulatory setting short of...

POLST forms within an acute care setting

There are only a limited number of studies on the content and completion of Physician Orders for Life Sustaining Treatment (POLST) forms. No study has specifically examined the use of...

How ePOLST will improve shared, informed medical decision-making: applying the eMOLST experience in New York

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program is designed to improve the quality of care seriously ill patients receive at the end of life. The process results in...

Advance Care Planning in CKD/ESRD

Advance care planning was historically considered to be simply the completion of a proxy (health care surrogate designation) or instruction (living will) directive that resulted from a conversation between a patient and his or her physician. We now know that advance care planning is a much more comprehensive and dynamic patient-centered process used by patients and families to strengthen relationships, achieve control over medical care, prepare for death, and clarify goals of care. Some advance directives, notably designated health care proxy documents, remain appropriate expressions of advance care planning. Moreover, although physician orders, such as do-not-resuscitate orders and Physician Orders for Life-Sustaining Treatment, may not be strictly defined as advance directives, their completion, when appropriate, is an integral component of advance care planning. The changing health circumstances and illness trajectory characteristic of ESRD mandate that advance care planning discussions adapt to a patient's situation and therefore must be readdressed at appropriate times and intervals. The options of withholding and withdrawing dialysis add ESRD-specific issues to advance care planning in this population and are events each nephrologist will at some time confront. Advance care planning is important throughout the spectrum of ESRD and is a part of nephrology practice that can be rewarding to nephrologists and beneficial to patients and their families.

POLST

POLST

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.

Editorial: Advancing the advance care planning process

Editorial: Advancing the advance care planning process

Aligning Patient Preferences and Patient Care at the End of Life

Aligning Patient Preferences and Patient Care at the End of Life

The Physician Order for Life-Sustaining Treatment in Case of Emergency (POLST-E) as an integral part of the patient advance directive: what are nursing home residents' preferences resulting from a facilitated advance care planning process?

BackgroundTreatment decisions in emergencies when the patient is (acutely) incapable pose a challenge for nursing and emergency staff, especially if the attending physician and/or the designated proxy are not available....

Advances in Palliative Medicine and End-of-Life Care

Palliative care improves the quality and cost-effectiveness of adult and pediatric patient care, and it decreases unwanted hospitalizations and aggressive care at the end of life. National palliative care quality standards and preferred practices can be used for benchmarking by institutions, health care systems, and accrediting bodies. Pain and symptom management and the management of delirium for patients is now possible for the vast majority of patients, even those with advanced disease. However, because of shortages of specialists providing "tertiary" palliative care, significant improvements are needed in generalist-level palliative care among oncologists, intensivists, and specialists caring for patients with advanced cardiac, pulmonary, renal, and hepatic diseases. POLST (Physician Orders for Life-Sustaining Treatment) forms are a major advance in end-of-life care. They enable patients' advance directives to be valid wherever they are cared for (home, hospital, or nursing facility).

The National POLST Paradigm Initiative, 2nd Edition #178

Journal of Palliative MedicineVol. 14, No. 2 Fast Facts and ConceptsThe National POLST Paradigm Initiative, 2nd Edition #178Judy Citko, Alvin H. Moss, Margaret Carley, and Susan TolleJudy CitkoSearch for more papers by this author, Alvin H. MossSearch for more papers by this author, Margaret CarleySearch for more papers by this author, and Susan TolleSearch for more papers by this authorPublished Online:12 Feb 2011https://doi.org/10.1089/jpm.2010.9730AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"The National POLST Paradigm Initiative, 2nd Edition #178." , 14(2), pp. 241–242FiguresReferencesRelatedDetailsCited byOutcomes of home‐based primary care for homebound older adults: A randomized clinical trial20 August 2022 | Journal of the American Geriatrics Society, Vol. 71, No. 2Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology1 September 2022 | Dementia & Neuropsychologia, Vol. 16, No. 3 suppl 1Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia1 September 2022 | Dementia & Neuropsychologia, Vol. 16, No. 3 suppl 1Death, dying, and end of life issues18 August 2021Renal Replacement Therapy in Patients With Stage IV Cancer Admitted to the Intensive Care Unit With Acute Kidney Injury at a Comprehensive Cancer Center Was Not Associated With Survival27 January 2020 | American Journal of Hospice and Palliative Medicine®, Vol. 37, No. 9The impact of language on the interpretation of resuscitation clinical care plans by doctors. A mixed methods study25 November 2019 | PLOS ONE, Vol. 14, No. 11Elderly patients presenting to a Level I trauma center with Physician Orders for a Life-Sustaining Treatment form: A propensity-matched analysis26 April 2019 | Journal of Trauma and Acute Care Surgery, Vol. 87, No. 1Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing FacilitiesJournal of the American Medical Directors Association, Vol. 18, No. 10Association of Physician Orders for Life-Sustaining Treatment Form Use With End-of-Life Care Quality Metrics in Patients With CancerJournal of Oncology Practice, Vol. 13, No. 10Advance Care Planning for Patients Approaching End-Stage Kidney DiseaseSeminars in Nephrology, Vol. 37, No. 2Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents17 May 2016 | Journal of General Internal Medicine, Vol. 31, No. 10A Qualitative Inquiry on Palliative and End-of-Life Care Policy Reform Hannah C. Schreibeis-Baum, Lea E. Xenakis, Emily K. Chen, Mark Hanson, Sangeeta Ahluwalia, Gery Ryan, and Karl A. Lorenz1 April 2016 | Journal of Palliative Medicine, Vol. 19, No. 4Advance Care Planning and Preparing to Die19 March 2017How the ESRD Quality Incentive Program Could Potentially Improve Quality of Life for Patients on DialysisClinical Journal of the American Society of Nephrology, Vol. 10, No. 5End-of-life issues9 February 2015Ethical Issues in Chronic Kidney DiseasePatient-Centered Care: An Opportunity to Accomplish the “Three Aims” of the National Quality Strategy in the Medicare ESRD Program17 July 2014 | Clinical Journal of the American Society of Nephrology, Vol. 9, No. 12Dying on Dialysis: The Case for a Dignified Withdrawal22 August 2013 | Clinical Journal of the American Society of Nephrology, Vol. 9, No. 1Implementation of Physician Orders for Life Sustaining Treatment in Nursing Homes in California: Evaluation of a Novel Statewide Dissemination Mechanism10 August 2012 | Journal of General Internal Medicine, Vol. 28, No. 1How Is the Patient Who Stops Dialysis Best Managed?Advance Care Planning in CKD/ESRDClinical Journal of the American Society of Nephrology, Vol. 7, No. 6The Need for Safeguards in Advance Care Planning12 January 2012 | Journal of General Internal Medicine, Vol. 27, No. 5Integrative Therapies to Support Palliative and End-of-Life Care in Lung Disease7 December 2011 Volume 14Issue 2Feb 2011 InformationCopyright 2011, Mary Ann Liebert, Inc.To cite this article:Judy Citko, Alvin H. Moss, Margaret Carley, and Susan Tolle.The National POLST Paradigm Initiative, 2nd Edition #178.Journal of Palliative Medicine.Feb 2011.241-242.http://doi.org/10.1089/jpm.2010.9730Published in Volume: 14 Issue 2: February 12, 2011PDF download

A complex regional intervention to implement advance care planning in one town's nursing homes: Protocol of a controlled inter-regional study

BackgroundAdvance Care Planning (ACP) is an emerging strategy to ensure that well-reflected, meaningful and clearly documented treatment preferences are available and respected when critical decisions about life-sustaining treatment need to be made for patients unable to consent. In Germany, recent legislation confirms that advance directives (AD) have to be followed if they apply to the medical situation, but implementation of ACP has not yet been described.Methods/DesignIn a longitudinal controlled study, we compare 1 intervention region (4 nursing homes [n/hs], altogether 421 residents) with 2 control regions (10 n/hs, altogether 985 residents). Inclusion went from 01.02.09 to 30.06.09, observation lasted until 30.06.10. Primary endpoint is the prevalence of ADs at follow-up, 17 (12) months after the first (last) possible inclusion. Secondary endpoints compare relevance and validity of ADs, process quality, the rate of life-sustaining interventions and, in deceased residents, location of death and intensity of treatment before death. The regional multifaceted intervention on the basis of the US program Respecting Choices® comprises training of n/h staff as facilitators, training of General Practitioners, education of hospital and ambulance staff, and development of eligible tools, including Physician Orders for Life-Sustaining Treatment in case of Emergency (POLST-E).Participation data: Of 1406 residents reported to live in the 14 n/hs plus an estimated turnover of 176 residents until the last possible inclusion date, 645 (41%) were willing to participate. Response rates were 38% in the intervention region and 42% in the control region. Non-responder analysis shows an equal distribution of sex and age but a bias towards dependency on nursing care in the responder group. Outcome analysis of this study will become available in the course of 2011.DiscussionImplementing an ACP program for the n/hs and related health care providers of a region requires a complex community intervention with the effect of nothing less than a cultural shift in this health care sector. This study is to our knowledge the first to develop a strategy for regional implementation of ACP, and to evaluate its feasibility in a controlled design.Trial RegistrationISRCTN: ISRCTN99887420