New Program Improves Communication, Adherence to
End-of-Life Wishes
Power of new Physician Orders for Life-Sustaining
Treatment (POLST) is signature of a physician
July 12, 2010 - Various studies and reports have
raised serious questions about how well end-of-life directives are
followed in real-life situations. But, a new program, in which people
use a standardized form signed by a physician to communicate their
end-of-life care preferences on issues such as levels of medical
intervention and tube feeding lead to significantly better adherence to
treatment preferences than more traditional methods of communication,
according to a new study of nursing home patients.
The program, called Physician Orders for
Life-Sustaining Treatment (POLST), is designed for individuals with
progressive chronic illness or frailty. POLST was first developed in
Oregon in 1990 in response to concerns that traditional
Do-Not-Resuscitate (DNR) orders and advance directives do not adequately
communicate patients’ wishes for the many treatment decisions they face
at the end of their lives.
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adequately trained to provide the complex care needed by older adults
with multiple chronic conditions’
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The POLST program, which is now in use or under
development in over 30 states, includes a standardized form on which
patient preferences are listed as physician orders for -
● cardiopulmonary resuscitation (CPR);
● medical interventions such as comfort measures
(non-life-sustaining measures to relieve pain and suffering),
● limited intervention or full treatment;
● use of antibiotics; and
● tube feeding.
The order forms are included with an individual’s
medical charts as the person moves through the health care system.
The study, supported by the National Institute of
Nursing Research (NINR), part of the National Institutes of Health,
appears in the July issue of the Journal of the American Geriatrics
Society. This study was the first to directly compare this program to
traditional practices such as Do-Not-Resuscitate (DNR) orders.
Using 60-day chart data from more than 1,700 living
and deceased long-stay nursing facility residents in Oregon, Wisconsin,
and West Virginia, the study analyzed the levels of treatment received
by residents with or without POLST forms or traditional medical orders
such as a DNR order.
The study found that residents who used a POLST
form to indicate their preference for comfort care only were 59 percent
less likely to receive life-sustaining medical interventions that were
not requested, when compared to residents with DNR orders, suggesting
that POLST promotes closer adherence to documented treatment preferences
than DNR orders.
Similarly, residents with POLST orders for comfort
care only were 67 percent less likely to receive life-sustaining
treatments than those with POLST orders for full treatment. Overall,
residents with POLST forms were also more likely to have treatment
preferences documented as medical orders than those without POLST forms.
"It is fairly common for nursing facility residents
to have orders about CPR in their medical charts. However, CPR orders
alone are not very helpful in telling the health care provider about the
person’s interest in receiving other treatments," stated lead author
Susan Hickman, Ph.D., associate professor in the schools of nursing at
Indiana University and Oregon Health & Science University.
"In our study, 98 percent of residents with POLST
forms had orders about medical interventions beyond resuscitation, in
comparison to just 16 percent without POLST forms. This means they had
orders about their preferences for treatments such as hospitalization,
antibiotics, and feeding tube use. POLST tends to provide much more
specificity for care providers."
The study also found no significant difference in
reported symptom frequency or in the level of symptom management
provided to residents who were POLST users compared to non-POLST users.
This finding indicates that the presence of a POLST order did not impact
the degree of comfort care received by the residents.
"Many individuals and their families still struggle
with a lack of continuity of care and poor communication with health
care practitioners about their treatment wishes," noted NINR Director
Patricia A. Grady, Ph.D., RN.
"This study underscores the importance of
identifying effective ways to make sure that the type of end-of-life
health care requested by the individual is in fact provided. Health care
professionals can use this information to help individuals make better
informed choices about the type and level of care they wish to receive."
NINR supports basic and clinical research that
develops the knowledge to build the scientific foundation for clinical
practice, prevent disease and disability, manage and eliminate symptoms
caused by illness, and enhance end-of-life and palliative care.
To learn more about POLST, including forms for
participating states, visit
www.polst.org.
For more information about NINR, visit the Web site
at
www.ninr.nih.gov.
The National Institutes of Health (NIH) — The
Nation's Medical Research Agency — includes 27 Institutes and Centers
and is a component of the U.S. Department of Health and Human Services.
It is the primary federal agency for conducting and supporting basic,
clinical and translational medical research, and it investigates the
causes, treatments, and cures for both common and rare diseases. For
more information about NIH and its programs, visit
www.nih.gov.
November 16, 2009 - NPR's Joseph Shapiro visits to
La Crosse, Wisconsin and explains in All Things Considered why Gundersen
Lutheran is often used as a model for good end-of-life care.
Click here for the story.
October, 2009 - Community Conversations on
Compassionate Care is a program developed by Excellus BlueCross
BlueShield to help individuals over 18 years of age complete health care
proxies and living wills.
Click here for PDF .
July 12, 2010 - Various studies and reports have
raised serious questions about how well end-of-life directives are
followed in real-life situations. But, a new program, in which people
use a standardized form signed by a physician to communicate their
end-of-life care preferences on issues such as levels of medical
intervention and tube feeding lead to significantly better adherence to
treatment preferences than more traditional methods of communication,
according to a new study of nursing home patients.
