Nearly half of California nursing home residents complete end-of-life care orders

UCLA-led research finds broad acceptance of written end-of-life care orders among California nursing home residents, with nearly half completing a Physician Orders for Life-Sustaining Treatment, or POLST, form in 2011.

The study, published online in the peer-reviewed Journal of General Internal Medicine, also found no difference in completion of the form by race or ethnicity, suggesting wide acceptance of these orders among California's highly diverse population. The researchers did, however, identify a few areas where the use of the forms in nursing homes could be improved.

The POLST document records a patient's end-of-life care preferences regarding cardiopulmonary resuscitation, aggressiveness of medical interventions and artificial nutrition. Printed on bright pink paper, and signed by the patient as well as a doctor, nurse practitioner or physician assistant, the form is designed to travel with a patient to different care settings, such as hospitals, nursing homes or doctor's offices. It was enacted for use in California through AB 3000 legislation in 2009. Completion of the order by the individual is voluntary.

"POLST is an especially useful tool for nursing home residents because they often experience transitions from the nursing home to the hospital or emergency department and back again," said Dr. Lee Jennings, assistant professor of medicine in the division of geriatrics at the David Geffen School of Medicine at UCLA, and the study's lead author. "It is an effective tool for reducing unnecessary transfers and communicating a patient's preferences to a doctor in a new care setting who may not know the patient well, especially if a patient does not want aggressive medical interventions at the end of life."

This is the first study of a life-sustaining treatment form using the Long-Term Care Minimum Data Set, or MDS, a federally mandated clinical assessment of all residents in nursing homes certified by Medicare or Medicaid. To date, California is the only state to have added questions about completion of the orders to the data set.

"The broad adoption of POLST in California's nursing homes is possible due to a combination of state-level efforts—such as passing legislation and developing a standardized POLST form and curriculum—and the grassroots efforts of local POLST coalitions who educate providers and consumers in cities and counties throughout the state," said Judy Thomas, study co-author and CEO of the Coalition for Compassionate Care of California, the organization that runs the POLST program in California. "Analysis of the MDS data confirms the effectiveness of grassroots outreach efforts, and will also help us focus on the facilities or communities in need of additional support to ensure best practices are being followed for POLST implementation."

The researchers evaluated use of the form among all California nursing home residents, including variation by resident characteristics and by nursing home facility. They used statewide data of POLST completion in nursing homes, which included 296,276 people with a stay in one of 1,220 California nursing homes in 2011.

Among their findings:

• Completion increased from 33 percent at the beginning of 2011 to 49 percent by the end of that year.
• Long-stay nursing home residents were more likely than short-stay residents to have completed the form.
• Severely cognitively impaired long-term care residents were 24 percent less likely than unimpaired residents to have completed the order.
• The study shows no difference in completion among white non-Hispanic, black and Hispanic residents.
• There was wide variation between facilities in completion of the form, with 20 percent having low completion (less than 10 percent of their long-term care residents) and 40 percent having high completion (more than 80 percent of their long-term care residents)
• 13 percent of the forms lacked a signature, rendering the order invalid.

"We need to better understand why some facilities are able to complete POLSTs with many of their residents while others complete very few," Jennings said.

The authors note that up-to-date data are needed in order to guide intervention. "But these results demonstrate how MDS data can be used to target quality improvement," they write.