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End-of-Life Care Orders Completed for Almost Half of NH Residents in California

July 14, 2016

A recent UCLA study found that nearly half of nursing home (NH) residents in California completed end-of-life Physician Orders for Life-Sustaining Treatment (POLST) in 2011, with no difference in completion of the form by race or ethnicity (Journal of General Internal Medicine 2016).

This is the first study of a life-sustaining treatment form using the Long-Term Care Minimum Data Set (MDS), and, to date, California is the only state to have added questions about completion of the orders to the data set.
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For the study, researchers conducted an observational study of 296,276 people with a stay in 1,220 California NHs in 2011, using the California MDS Section S. They investigated the proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; changes in POLST use during 2011; and POLST completion and unsigned forms within NHs.

During 2011, POLST completion increased from 33% to 49% of California NH residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status.

There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. There was wide variation between facilities in completion of the form, with 20% having low completion (less than 10% of their residents) and 40% having high completion (more than 80% of their residents).

Overall, long-stay NH residents were more likely than short-stay residents to have completed the form. Severely cognitively impaired residents were 24% less likely than unimpaired residents to have completed the order. Thirteen percent of NH residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid.

Lead author Lee Jennings, MD, said, “We need to better understand why some facilities are able to complete POLSTs with many of their residents while others complete very few.” Dr Jennings and colleagues 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. —Amanda Del Signore

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