Some NHs Use POLST Inappropriately; Practice, Policy, Research Considerations Can Help
The COVID pandemic brought a renewed focus on the importance of advance care planning (ACP) and identifying preferences for care and interventions prior to a medical emergency. There are various forms and processes that can be used for this purpose. One of these involves the POLST (Physician Orders for Life Sustaining Treatment) paradigm. POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limited medical condition. However, according to the authors of an article in the August issue of JAMDA, some nursing homes (NHs) are using it in potentially inappropriate ways with patients who are ineligible because they are not at such risk. They also make recommendations for NHs to implement the appropriate use of POLST.
In POLST Is More Than a Code Status Order Forum: Suggestions for Appropriate POLST Use in Long-term Care, the authors cited studies identifying issues with the use of POLST in NHs, including staff difficulty understanding and explaining the form, discomfort with issues raised by the form, and problems using the form to guide treatment. They observed that one problematic practice that contributes to these difficulties is the use of POLST as a universal code status form to document cardiopulmonary resuscitation (CPR) orders. “Although POLST includes medical orders for a range of interventions, some nursing homes are using POLST as the default mechanism for documenting code status on all residents,” the authors said.
To prevent the inappropriate use of POLST in NHs, the authors suggested several considerations for practice, policy, and research. Specifically, they recommend assessing and identifying which nursing home residents are eligible and appropriate for POLST; using alternate approaches to document and communicate code status; reviewing and revising specific policies for code status orders and appropriate use of POLST; conducting ongoing staff training about POLST; and leveraging state survey agencies and surveyors to promote appropriate POLST use.
POLST is designed to be completed following a conversation between a health-care provider and the patient and/or their legal representative. Ideally, it includes an exploration of goals, values, and treatment preferences that are documented as orders about CPR, medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. POLST goes by various names, including POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), among others.
The study was conducted by researchers at Indiana University School of Nursing, Indianapolis, IN; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN; California State University Institute for Palliative Care, Oceanside, CA; Center for Practical Bioethics, Kansas City, MO; VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO; and Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO.
JAMDA is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. JAMDA publishes peer-reviewed articles including original studies, reviews, clinical experience articles, case reports, and more, on all topics more important to post-acute and long-term care medicine. Visit www.jamda.com for more information.
About AMDA – The Society for Post-Acute and Long-Term Care Medicine
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long-term care (PALTC) settings. Dedicated to defining and improving quality, we advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of members, patients, families, and staff. Visit www.paltc.org for more information.