Nursing home patients are more likely to receive the treatment they want and less likely to have unwanted hospitalizations and medical interventions under a program using medical forms signed by a physician that detail the patients' decisions about end-of-life care, according to a new study.
Researchers examined the impact of a program where patients fill out the medical forms that record whether they want to receive CPR, hospitalization, and treatments like antibiotics, feeding tubes, and other medical interventions. Doctors review and sign the form and it is added to the patient's medical file. The program -- Physicians Orders for Life-Sustaining Treatment (POLST) – started because of concerns that traditional patient-generated orders and advance directives were often too vague or did not offer enough details to be helpful in a clinical setting.
"It is really unusual to find something that has an effect on the kind of treatments people receive and ensure that they are consistent with what they want. It seems like it should be easy to do and it's actually really, really hard," said Susan Hickman, of Indiana University, who is the lead author of the study.
The study found that people with POLST forms who said they wished to receive care primarily for pain relief were 59 percent less likely to receive unwanted treatments than those with only a "Do Not Resuscitate" order. POLST participants who requested fewer medical interventions still received pain management treatments at similar levels to other patients, while those who asked for full treatment on their POLST forms were just as likely to receive it as other patients. The program also allows patients who do not want extraordinary resuscitation measures to detail other treatments that they do want.
Co-author Susan Tolle, of the Oregon Health & Science University, said that the default practice is to do everything possible despite the fact that only about 12 percent of nursing home patients want intensive care treatments. The majority of patients prefer limited treatment and the program allows them to receive the exact level of care they desire, she said. "There are many health care professionals who welcome this, particularly emergency medical personnel," Tolle said.
The study examined the medical records of 1,711 nursing facility patients in the POLST program in West Virginia, Wisconsin and Oregon, where it launched in 1990. Since then, POLST and similar programs have expanded to 32 states.
The study is published in this month's issue of the Journal of the American Geriatrics Society.
Hickman attributes the program's success to its systemic nature and the fact that the forms are written in clear, clinical language. "It isn't just a piece of paper, it's really a program that involves coordination between hospitals, nursing facilities, hospice programs and emergency medical services. It's a program in which everyone is on board and understands what the goals are, what to do when they see a form, how to move it through the system so that it doesn't get lost but stays with a patient as it's intended," Hickman said.
View a sample POLST form.