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.

Jennings LA ，Wenger NS ，Liang LJ ，Parikh P ，Powell D ，Escarce JJ ，Zingmond D ... -  《-》

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents.

Jennings LA ，Zingmond D ，Louie R ，Tseng CH ，Thomas J ，O'Malley K ，Wenger NS ... -  《-》

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.

Zingmond DS ，Powell D ，Jennings LA ，Liang LJ ，Escarce JJ ，Parikh P ，Wenger NS ... -  《-》

Nursing Home Residents' Preferences on Physician Orders for Life Sustaining Treatment.

Previous studies examining preferences documented in Physician Orders for Life Sustaining Treatment (POLST) have found that most sampled POLSTs show a preference to limit care. These studies were conducted in states that are relatively ethnically homogeneous. This study investigated the POLST preferences of nursing home residents in an ethnically diverse state-California-that requires nursing homes to document whether residents execute POLST. Data were collected from POLST forms executed by 941 residents in a convenience sample of 13 nursing homes in Southern California. The study analyzed data from 4 POLST form items: signatory (resident vs. surrogate decision-maker) and care preferences related to: (a) resuscitation; (b) medical intervention; and (c) artificially administered nutrition. Descriptive, comparative, and regression analyses are reported at both individual and facility levels. Of reviewed POLSTs, 46.8% documented a preference for "do not resuscitate" (DNR); 47.3% documented limits on medical intervention; and 52% documented limits on artificially administered nutrition. Residents in nursing homes serving comparatively larger populations of older residents and White residents had lower odds of electing the full care option for each of the POLST's 3 care items; those in nursing homes serving comparatively larger populations of Hispanic residents had higher odds of electing long-term artificially administered nutrition. This study found lower rates of POLST choices limiting care than previous studies, possibly because the sampled nursing homes served a more ethnically- and age-diverse population. California's requirement that nursing homes document whether residents execute POLST also may have indirectly influenced choice patterns.

Rahman AN ，Bressette M ，Gassoumis ZD ，Enguidanos S ... -  《-》

Relationship of POLST to Hospitalization and ICU Care Among Nursing Home Residents in California.

Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients' wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population. Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California. Retrospective cohort study using the Minimum Data Set linked to California Section S (POLST documentation), the Medicare Beneficiary Summary File, and Medicare line item claims. California nursing home residents with Medicare fee-for-service insurance, 2011-2016. Hospitalization, days in the hospital, and days in the intensive care unit (ICU) after adjustment for resident and nursing home characteristics. The 1,112,834 residents had a completed and signed (valid) POLST containing orders for CPR with Full treatment 29.6% of resident-time (in person-years) and a DNR order with Selective treatment or Comfort care 27.1% of resident-time. Unsigned POLSTs accounted for 11.3% of resident-time. Residents experienced 14 hospitalizations and a mean of 120 hospital days and 37 ICU days per 100 person-years. Residents with a POLST indicating CPR Full treatment had utilization nearly identical to residents without a POLST. A gradient of decreased utilization was related to lower intensity of care orders. Compared to residents without a POLST, residents with a POLST indicating DNR Comfort care spent 56 fewer days in the hospital and 22 fewer days in the ICU per 100 person-years. Unsigned POLST had a weaker and less consistent relationship with hospital utilization. Among California NH residents, there is a direct relationship between intensity of care preferences in POLST and hospital utilization. These findings emphasize the importance of a valid POLST capturing informed preferences for nursing home residents.

Zingmond D ，Powell D ，Jennings LA ，Escarce JJ ，Liang LJ ，Parikh P ，Wenger NS ... -  《-》