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New Study Shows Impact of Program Allowing Patients to Document Wishes for End-of-Life Treatment

Medical order program available in California is linked to lower rates of unwanted hospitalization

A study found that nursing home patients with POLST forms saying they wanted care primarily focused on relieving pain and suffering were less likely to receive unwanted treatments than those who had only a DNR order.

A new study has found that nursing home patients participating in a program enabling them to record their wishes for end-of-life treatment are far less likely to receive unwanted hospitalization and medical interventions than are other patients.

The program, known in California as Physician Orders for Life-Sustaining Treatment (POLST), uses an innovative medical order form signed by physicians — and, in California, patients — that allows patients to specify whether or not they prefer to receive CPR, hospitalization, and treatments like antibiotics, feeding tubes, and other medical interventions. 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.

The process has been adopted in 250 nursing homes, hospitals, and long term care facilities in California.

The study found that patients with POLST forms saying they wished to receive care primarily focused on relieving their pain and suffering were 59 percent less likely to receive unwanted treatments such as hospitalization than those who had only a DNR order. At the same time, the study showed that patients with POLST forms requesting fewer medical interventions continued to receive pain management; when compared to other patients, they were found to receive identical levels of treatment for pain and other symptoms.

"Traditional approaches such as DNR orders don’t tell us about a patient’s wishes regarding other kinds of treatments. In our study, 98 percent of residents with POLST forms had orders about medical interventions in addition to resuscitation, compared with just 16 percent of residents without POLST forms," said lead author, Susan Hickman, Ph.D., associate professor in the Schools of Nursing at Indiana University and Oregon Health & Science University. "The bottom line is that POLST translates patients’ wishes about a range of treatments into medical orders that are easily understood by health care professionals and can be acted upon immediately."

The study was published in the July 2010 issue of the Journal of the American Geriatrics Society.

There is a strong effort at local and state levels to increase awareness and use of POLST in California. The Coalition for Compassionate Care of California (CCCC), with support from the California HealthCare Foundation, is working with a statewide task force and 18 local coalitions to broadly implement POLST throughout the state.

"We have created a strong training program in California to teach medical providers how to talk with patients and their families about POLST and end-of-life care," said Judy Citko, executive director of CCCC.

"The main point of POLST is to encourage communication between providers, patients, and their loved ones, so patients can make more informed decisions and clearly communicate these decisions to their health care providers," said Kate O’Malley, senior program officer at the California HealthCare Foundation, which is funding training and outreach for POLST.

On POLST forms patients may indicate a preference for all available treatments. And in those cases, the study found that patients with a POLST form requesting full treatment received the same level of treatment as those patients with traditional orders requesting full treatment.

"Only about 12 percent of nursing home patients want intensive care. But this study shows that if that’s their preference, POLST helps ensure they’ll receive full treatment," said Susan Tolle, M.D., director of the Center for Ethics in Health Care at the Oregon Health & Science University and co-author on the study. "POLST allows patients to tell their health care professionals exactly what they want, so providers know patients’ wishes no matter what level of treatment they are seeking."

The study, titled "A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life-Sustaining Treatment Program," was funded by the National Institute of Nursing Research. It tracked the impact of the POLST program by analyzing the medical records of 1,711 nursing facility patients in Oregon, West Virginia, and Wisconsin. Thirty-two states have implemented POLST or are developing similar programs.

To learn more about POLST, visit www.caPOLST.org.

About the Coalition for Compassionate Care of California

The Coalition for Compassionate Care of California is a statewide partnership of nearly 200 regional and statewide organizations dedicated to the advancement of palliative medicine and end-of-life care in California. CCCC provides leadership and oversight for POLST outreach activities in California. Additional information on the California POLST program is available at www.CoalitionCCC.org.

About the California Health Care Foundation

CHCF is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.

CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system.

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