INTRODUCTION

Physician Orders for Life-Sustaining Treatment (POLST) can effectively transmit decisions about aggressiveness of care for nursing home (NH) residents across time and settings.1-3 However, POLST requires valid completion, continuity, and availability to ensure care consistent with goals.4, 5 These aspects of POLST use have been studied only in narrow samples over brief periods6 or through registries.4, 7 California implemented POLST in 2009 and since 2011 California NHs were required to report POLST completion and content in a supplemental section of the Minimum Data Set (MDS). We used MDS 2011–2016 linked to California Section S to describe POLST completion, cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR) orders, invalid POLST documents, and switches in POLST content across the population of California NH residents.

METHODS

MDS is a federally mandated resident assessment tool completed in Medicare/Medicaid-certified NHs. MDS collects demographic and clinical information, including cognitive and functional status. California Section S captures the content of the most recent POLST in the medical chart including CPR/DNR preference (in POLST Section A). For each NH resident, we created a longitudinal description of POLST from 2011 to 2016. We classified a POLST as valid if resuscitation preference and both clinician and patient/proxy signatures were present.

Because POLST use differs between long- and short-stay residents2, 8 and because we postulated that POLST would be inconsistently transmitted to a new NH, we evaluated POLST completion, content, and changes for long-stay and short-stay residents and whether a resident changed NHs. We evaluated whether residents had a valid POLST (signed CPR or signed DNR), signature missing POLST (CPR or DNR), Section A not completed, or absent POLST. Each POLST observation was weighted by the number of days from each MDS assessment to the next, reflecting the time a POLST was in effect, truncated at 100 days (methods detailed in Appendix S1).

We examined whether POLST completion and preferences changed within residents over time by counting switches (i.e., change in POLST presence, resuscitation preference, or signatures). This was described among residents changing NHs and within an NH stay, presented as the number of POLST changes per facility stay and per day in a facility.

RESULTS

From 2011 to 2016, there were 1,120,375 unique California NH residents; 83% of NH occupancy time was accrued by the 17% long-stay residents (characteristics in Table S1). POLST use increased among California NH residents from 65.8% in 2011 to 83.2% in 2016. Residents with a valid CPR order increased from 21.3% to 33.0% and DNR orders increased from 25.6% to 35.0% (Figure 1A). Unsigned DNR orders decreased from 5.3% to 3.6%, while unsigned CPR orders decreased from 6.5% to 6.1%. Long-stay residents tracked with the overall sample; short-stay unsigned CPR orders remained unchanged while unsigned DNR orders decreased (Figure 1B,C).

Changes in Physician Orders for Life-Sustaining Treatment (POLST) completion in the following categories: (1) cardiopulmonary resuscitation (CPR), signed, (2) CPR, not signed, (3) do not resuscitate (DNR), signed, (4) DNR, not signed, (5) no Section A, and (6) POLST missing for all nursing home residents (A), long-stay residents (B), and short-stay residents (C)

Eighty-nine percent of residents had no changes in POLST during the NH stay. Across 100 NH stays, there were 11.2 switches in POLST or POLST content (1.3 switches per 365 facility days) (Table S2). POLST discontinuity was much more common when changing facilities: 61% of NH changes were associated with a change in POLST completion or care preference (Table S3). POLST changes among NH residents with confirmed hospitalizations were similar to the overall NH population (Table S4).

DISCUSSION

POLST completion steadily increased during the first 6 years of reporting for California NH residents. By 2016, two thirds of patients' time in NHs carried resuscitation preferences in a valid POLST. The proportion of time covered by valid POLST orders increased and unsigned forms decreased over the 6 years.

These comprehensive data demonstrate that POLST provides excellent continuity of resuscitation preferences throughout an NH stay with nearly nine of 10 residents having no change in POLST. However, NH transition poses a threat to POLST continuity with 60% of residents entering a new NH with POLST existence or content different than their prior NH stay. Whether this represents change in prognosis or preferences, or inattention to continuity merits exploration and remedy.

Although NH residents spend only 15% of their time with a POLST that is invalid because of a missing signature or incomplete Section A, addressing clinical decompensation during this period would be potentially problematic. If a patient with such a POLST was transferred to an emergency room, the POLST likely would provide little—or perhaps confusing—guidance.

Limitations of this retrospective study of California NH residents include uncertain generalizability to other states, acknowledgment that care preferences for residents without a completed POLST cannot be determined, and recognition that administrative data cannot determine appropriate POLST completion nor distinguish between MDS and POLST data quality issues.

This comprehensive assessment of NH POLST use in a large state where POLST adoption is mature and universal reporting standards exist suggests that POLST represents a reliable mechanism for capturing NH resident care preferences, but also delineates areas for improvement.

ACKNOWLEDGMENTS

The authors thank Rachel Louie for her work in data management and statistical programming for this study.

CONFLICT OF INTEREST

All authors declare that they have no financial or personal conflicts of interest with regard to this manuscript.

AUTHOR CONTRIBUTIONS

All authors met criteria for authorship as follows: study concept and design (David Zingmond, David Powell, Lee A. Jennings, Jose J. Escarce, Li-Jung Liang, Punam Parikh, and Neil S. Wenger); acquisition of data (David Zingmond and Punam Parikh); analysis and interpretation of data (David Zingmond, David Powell, Lee A. Jennings, Jose J. Escarce, Li-Jung Liang, Punam Parikh, and Neil S. Wenger); and preparation of manuscript (David Zingmond, David Powell, Lee A. Jennings, Jose J. Escarce, Li-Jung Liang, Punam Parikh, and Neil S. Wenger). All authors approved the final manuscript. No un-named contributor played a role in manuscript preparation.

SPONSOR'S ROLE

This project was funded by NIA R01AG055751. The funder played no role in the design, methods, analysis, or preparation of the paper.

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Appendix S1. Detailed methods.

Table S1. Demographics of California nursing home residents from 2011 to 2016.

Table S2. Switches in POLST documentation during a nursing home stay in California from 2011 to 2016.

Table S3. POLST change per 100 resident facility changes in California from 2011 to 2016.

Table S4. POLST change per 100 facility changes for residents with Medicare fee-for-service insurance in California from 2011 to 2016, with and without a hospitalization between facilities.

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REFERENCES

1Tark A, Song J, Parajuli J, Chae S, Stone PW. Are we getting what we really want? A systematic review of concordance between physician orders for life-sustaining treatment (POLST) documentation and subsequent care delivered at end-of-life. Am J Hosp Palliat Care. 2021; 38: 1142- 1158. 2Hickman SE, Torke AM, Sachs GA, et al. Do life-sustaining treatment orders match patient and surrogate preferences? The role of POLST. J Gen Intern Med. 2021; 36: 413- 421. 3Vranas KC, Plinke W, Bourne D, et al. The influence of POLST on treatment intensity at the end of life: a systematic review. J Am Geriatr Soc. 2021; 69(12): 3661- 3674. 4Moss AH, Zive DM, Falkenstine EC, Dunithan C. The quality of POLST completion to guide treatment: a 2-state study. J Am Med Dir Assoc. 2017; 18: 810.e5- 810.e9. 5Rahman AN, Bressette M, Enguidanos S. Quality of physician orders for life-sustaining treatment forms completed in nursing homes. J Palliat Med. 2017; 20: 538- 541. 6Hickman SE, Christine AN, Smith-Howell E, Hammes BJ. Use of the physician orders for life-sustaining treatment program for patients being discharged from the hospital to the nursing facility. J Palliat Med. 2014; 17: 43- 49. 7Schmidt TA, Zive D, Fromme EK, Cook JN, Tolle SW. Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST Registry. Resuscitation. 2014; 85: 480- 485. 8Jennings LA, Zingmond D, Louie R, et al. Use of the physician orders for life-sustaining treatment among California nursing home residents. J Gen Intern Med. 2016; 31: 1119- 1126.