IU Indianapolis ScholarWorks :: Browsing by Author "Hammes, Bernard J."

Browsing by Author "Hammes, Bernard J."

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A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Life-Sustaining Treatment (POLST) Program
(2010) Hickman, Susan E.; Nelson, Christine A.; Perrin, Nancy A.; Moss, Alvin H.; Hammes, Bernard J.; Tolle, Susan W.
Background Traditional methods to communicate life-sustaining treatment preferences are largely ineffective. The Physician Orders for Life-Sustaining Treatment (POLST) Program offers an alternative approach, but comparative data are lacking. Objectives To evaluate the relationship between communication methods (POLST versus traditional practices) and documentation of life-sustaining treatment orders, symptom assessment and management, and use of life-sustaining treatments. Design Retrospective observational cohort study conducted between June 2006 and April 2007. Setting A stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia. Subjects 1711 living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Measurements Life-sustaining treatment orders; pain, shortness of breath, and related treatments over a 7-day period; and use of life-sustaining treatments over a 60-day period. Results POLST users were more likely to have orders about life-sustaining treatment preferences beyond CPR than non-POLST users (98.0% vs. 16.1%, P<.001). There were no differences between POLST users and non-users in symptom assessment or management. POLST users with orders for Comfort Measures Only were less likely to receive medical interventions (e.g., hospitalization) than residents with POLST Full Treatment orders (P=.004), residents with Traditional DNR orders (P<.001), or residents with Traditional Full Code orders (P<.001). Conclusion POLST users were more likely to have treatment preferences documented as medical orders than non-POLST users but there were no differences in symptom management or assessment. POLST orders restricting medical interventions were associated with the lower use of life-sustaining treatments. Findings suggest the POLST program offers significant advantages over traditional methods to communicate preferences about life-sustaining treatments.
Do Life-sustaining Treatment Orders Match Patient and Surrogate Preferences? The Role of POLST
(Springer, 2021) Hickman, Susan E.; Torke, Alexia M.; Sachs, Greg A.; Sudore, Rebecca L.; Tang, Qing; Bakoyannis, Giorgos; Heim Smith, Nicholette; Myers, Anne L.; Hammes, Bernard J.; School of Nursing
Background: It is essential to high-quality medical care that life-sustaining treatment orders match the current, values-based preferences of patients or their surrogate decision-makers. It is unknown whether concordance between orders and current preferences is higher when a POLST form is used compared to standard documentation practices. Objective: To assess concordance between existing orders and current preferences for nursing facility residents with and without POLST forms. Design: Chart review and interviews. Setting: Forty Indiana nursing facilities (29 where POLST is used and 11 where POLST is not in use). Participants: One hundred sixty-one residents able to provide consent and 197 surrogate decision-makers of incapacitated residents with and without POLST forms. Main measurements: Concordance was measured by comparing life-sustaining treatment orders in the medical record (e.g., orders about resuscitation, intubation, and hospitalization) with current preferences. Concordance was analyzed using population-averaged binary logistic regression. Inverse probability weighting techniques were used to account for non-response. We hypothesized that concordance would be higher in residents with POLST (n = 275) in comparison to residents without POLST (n = 83). Key results: Concordance was higher for residents with POLST than without POLST (59.3% versus 34.9%). In a model adjusted for resident, surrogate, and facility characteristics, the odds were 3.05 times higher that residents with POLST had orders for life-sustaining treatment match current preferences in comparison to residents without POLST (OR 3.05 95% CI 1.67-5.58, p < 0.001). No other variables were significantly associated with concordance. Conclusions: Nursing facility residents with POLST are significantly more likely than residents without POLST to have concordance between orders in their medical records and current preferences for life-sustaining treatments, increasing the likelihood that their treatment preferences will be known and honored. However, findings indicate further systems change and clinical training are needed to improve POLST concordance.
Factors associated with concordance between POLST orders and current treatment preferences
(Wiley, 2021) Hickman, Susan E.; Torke, Alexia M.; Sachs, Greg A.; Sudore, Rebecca L.; Tang, Qing; Bakoyannis, Giorgos; Heim Smith, Nicholette; Myers, Anne L.; Hammes, Bernard J.; School of Nursing
Background: POLST is widely used to document the treatment preferences of nursing facility residents as orders, but it is unknown how well previously completed POLST orders reflect current preferences (concordance) and what factors are associated with concordance. Objectives: To describe POLST preference concordance and identify factors associated with concordance. Design: Chart reviews to document existing POLST orders and interviews to elicit current treatment preferences. Setting: POLST-using nursing facilities (n = 29) in Indiana. Participants: Nursing facility residents (n = 123) and surrogates of residents without decisional capacity (n = 152). Measurements: Concordance was determined by comparing existing POLST orders for resuscitation, medical interventions, and artificial nutrition with current treatment preferences. Comfort-focused POLSTs contained orders for do not resuscitate, comfort measures, and no artificial nutrition. Results: Overall, 55.7% (123/221) of residents and 44.7% (152/340) of surrogates participated (total n = 275). POLST concordance was 44%, but concordance was higher for comfort-focused POLSTs (68%) than for non-comfort-focused POLSTs (27%) (p < 0.001). In the unadjusted analysis, increasing resident age (OR 1.04, 95% CI 1.01-1.07, p < 0.01), better cognitive functioning (OR 1.07, 95% CI 1.02-1.13, p < 0.01), surrogate as the decision-maker (OR 2.87, OR 1.73-4.75, p < 0.001), and comfort-focused POLSTs (OR 6.01, 95% CI 3.29-11.00, p < 0.01) were associated with concordance. In the adjusted multivariable model, only having an existing comfort-focused POLST was associated with higher odds of POLST concordance (OR 5.28, 95% CI 2.59-10.73, p < 0.01). Conclusions: Less than half of all POLST forms were concordant with current preferences, but POLST was over five times as likely to be concordant when orders reflected preferences for comfort-focused care. Findings suggest a clear need to improve the quality of POLST use in nursing facilities and focus its use among residents with stable, comfort-focused preferences.
The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent
(2012-01) Hammes, Bernard J.; Rooney, Brenda L.; Gundrum, Jacob D.; Hickman, Susan E.; Hager, Nickijo
OBJECTIVES: Determine the use and utility of the Physician Orders for Life-Sustaining Treatment (POLST) program in a community where powers of attorney for health care (POAHCs) are prevalent. METHODS: A retrospective review of medical record and death certificate data of 400 adults who died between September 1, 2007, and March 31, 2008, in the La Crosse County, Wisconsin community. Demographic and cause-of-death data were collected from death certificates. Information about POAHC, POLST forms, and medical treatments provided in the last 30 days of life were abstracted from decedents' medical records. RESULTS: Sixty-seven percent of decedents had a POLST form, whereas 22% had POAHC alone. In comparison with decedents with POAHC alone, decedents with a POLST form were significantly older (83 versus 77 years, p<0.001), more likely to die in a nursing home than in a hospital (p<0.001), and more likely to die from a terminal or chronic illnesses (97%). Decedents with POLST orders for higher levels of medical treatment received more treatment, and in only two cases was there evidence that treatment was discrepant with POLST orders. In 31% of all POLST forms, the person appointed in the POAHC consented to the POLST orders. CONCLUSIONS: POLST can be a highly effective program to ensure that patient preferences are known and honored in all settings. POAHCs are valuable because they identify appropriate surrogates when patients are incapacitated.
Reasons for Discordance and Concordance between POLST Orders and Current Treatment Preferences
(Wiley, 2021) Hickman, Susan E.; Torke, Alexia M.; Heim Smith, Nicholette; Myers, Anne L.; Sudore, Rebecca L.; Hammes, Bernard J.; Sachs, Greg A.; School of Nursing
Background: The reasons for discordance between advance care planning (ACP) documentation and current preferences are not well understood. The POLST form offers a unique opportunity to learn about the reasons for discordance and concordance that has relevance for POLST as well as ACP generally. Design: Qualitative descriptive including constant comparative analysis within and across cases. Setting: Twenty-six nursing facilities in Indiana. Participants: Residents (n = 36) and surrogate decision-makers of residents without decisional capacity (n = 37). Measurements: A semi-structured interview guide was used to explore the reasons for discordance or concordance between current preferences and existing POLST forms. Findings: Reasons for discordance include: (1) problematic nursing facility practices related to POLST completion; (2) missing key information about POLST treatment decisions; (3) deferring to others; and (4) changes over time. Some participants were unable to explain the discordance due to a lack of insight or inability to remember details of the original POLST conversation. Explanations for concordance include: (1) no change in the resident's medical condition and/or the resident is unlikely to improve; (2) use of the substituted judgment standard for surrogate decision-making; and (3) fixed opinion about what is "right" with little to no insight. Conclusion: Participant explanations for discordance between existing POLST orders and current preferences highlight the importance of adequate structures and processes to support high quality ACP in nursing facilities. Residents with stable or poor health may be more appropriate candidates for POLST than residents with a less clear prognosis, though preferences should be revisited periodically as well as when there is a change in condition to help ensure existing documentation is concordant with current treatment preferences.
Reasons for Discordance Between Life-Sustaining Treatment Preferences and Medical Orders in Nursing Facilities Without POLST
(Sage, 2023) Heim Smith, Nicholette L.; Sudore, Rebecca L.; Myers, Anne L.; Hammes, Bernard J.; Hickman, Susan E.; School of Nursing
Background: Life-sustaining treatment (LST) orders are important communication tools used to ensure preference-concordant care at the end of life. Recent studies reveal concerning rates of discordance between current preferences and documented LST orders, especially in nursing facilities without POLST. Reasons for discordance in facilities using POLST have been explored, however the majority of nursing facilities in the United States do not yet use the POLST form. Design: Qualitative descriptive study using constant comparative analysis. Setting: Nursing facilities in Indiana (n = 6) not using POLST. Participants: Residents (n = 15) and surrogate decision-makers of residents without decisional capacity (n = 15) with discordance between current preferences and documented LST orders. Measurements: Do not resuscitate, do not hospitalize (DNH), and do not intubate (DNI) orders were extracted from medical charts. Current preferences were elicited using the Respecting Choices Advanced Steps model. A semi-structured interview guide was used to explore reasons for discordance between current preferences and LST orders. Results: Reasons for discordance included: (1) inadequate information about the range of available LST options, what each involves, and how to formally communicate preferences; (2) no previous discussion with facility staff; (3) no documentation of previously expressed preferences; and (4) family involvement. Conclusion: Reasons for discordance between expressed preferences and LST orders suggest that in facilities without a uniform and systematic LST order documentation strategy like POLST, these conversations may not occur and/or be documented. Staff should be aware that residents and surrogates may have preferences about LSTs that require strategic solicitation and documentation.
A Tool to Assess Patient and Surrogate Knowledge about the POLST (Physician Orders for Life-Sustaining Treatment) Program
(Elsevier, 2019) Hickman, Susan E.; Torke, Alexia M.; Sachs, Greg A.; Sudore, Rebecca L.; Myers, Anne L.; Tang, Qing; Bakoyannis, Giorgos; Hammes, Bernard J.; School of Nursing
Context It is especially important that patients are well-informed when making high stakes, preference-sensitive decisions like those on the Physician Orders for Life-Sustaining Treatment (POLST) form. However, there is currently no way to easily evaluate whether patients understand key concepts when making these important decisions. Objectives To develop a POLST knowledge survey. Methods Expert (n = 62) ratings of key POLST facts were used to select items for a POLST Knowledge Survey. The survey was administered to nursing facility residents (n = 97) and surrogate decision-makers (n = 112). A subset (n = 135) were re-administered the survey after a standardized advance care planning discussion to assess responsiveness of the scale to change. Results The 19-item survey demonstrated adequate reliability (α = 0.72.). Residents’ scores (x = 11.4, standard deviation 3.3) were significantly lower than surrogate scores (x = 14.7, standard deviation 2.5) (p < .001). Scores for both groups increased significantly following administration of a standardized advance care planning discussion (p < .001). Although being a surrogate, age, race, education, cognitive functioning, and health literacy were significantly associated with higher POLST Knowledge Survey scores in univariate analyses, only being a surrogate (p < 0.001) and being white (p = 0.028) remained significantly associated with higher scores in multivariate analyses. Conclusion The 19-item POLST Knowledge Survey demonstrated adequate reliability and responsiveness to change. Findings suggest the survey could be used to identify knowledge deficits and provide targeted education to ensure adequate understanding of key clinical decisions when completing POLST.
Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting
(2009-02) Hickman, Susan E.; Nelson, Christine A.; Moss, Alvin H.; Hammes, Bernard J.; Terwilliger, Allison; Jackson, Ann; Tolle, Susan W.
Background The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program was designed to ensure the full range of patient treatment preferences are honored throughout the health care system. Data are lacking about the use of POLST in the hospice setting. Objective To assess use of the POLST by hospice programs, attitudes of hospice personnel toward POLST, the effect of POLST on the use of life-sustaining treatments, and the types of treatments options selected by hospice patients. Design A telephone survey was conducted of all hospice programs in three states (Oregon, Wisconsin, and West Virginia) to assess POLST use. Staff at hospices reporting POLST use (n = 71) were asked additional questions about their attitudes toward the POLST. Chart reviews were conducted at a subsample of POLST-using programs in Oregon (n = 8), West Virginia (n = 5), and Wisconsin (n = 2). Results The POLST is used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff interviewed believe the POLST is useful at preventing unwanted resuscitation (97%) and at initiating conversations about treatment preferences (96%). Preferences for treatment limitations were respected in 98% of cases and no one received unwanted cardiopulmonary resuscitation (CPR), intubation, intensive care, or feeding tubes. A majority of hospice patients (78%) with do-not-resuscitate (DNR) orders wanted more than the lowest level of treatment in at least one other category such as antibiotics or hospitalization. Conclusions The POLST is viewed by hospice personnel as useful, helpful, and reliable. It is effective at ensuring preferences for limitations are honored. When given a choice, most hospice patients want the option for more aggressive treatments in selected situations.
Use of the Physician Orders for Life-Sustaining Treatment Program for Patients Being Discharged from the Hospital to the Nursing Facility
(2014-01) Hickman, Susan E.; Nelson, Christine A.; Smith-Howell, Esther; Hammes, Bernard J.
Background: The Physician Orders for Life-Sustaining Treatment (POLST) documents patient preferences as medical orders that transfer across settings with patients., Objectives: The objectives were to pilot test methods and gather preliminary data about POLST including (1) use at time of hospital discharge, (2) transfers across settings, and (3) consistency with prior decisions., Study Design: Descriptive with chart abstraction and interviews., Participants: Participants were hospitalized patients discharged to a nursing facility and/or their surrogates in La Crosse County, Wisconsin., Measurements: POLST forms were abstracted from hospital records for 151 patients. Hospital and nursing facility chart data were abstracted and interviews were conducted with an additional 39 patients/surrogates., Results: Overall, 176 patients had valid POLST forms at the time of discharge from the hospital, and many (38.6%; 68/176) only documented code status. When the whole POLST was completed, orders were more often marked as based on a discussion with the patient and/or surrogate than when the form was used just for code status (95.1% versus 13.8%, p<.001). In the follow-up and interview sample, a majority (90.6%; 29/32) of POLST forms written in the hospital were unchanged up to three weeks after nursing facility admission. Most (71.9%; 23/32) appeared consistent with patient or surrogate recall of prior treatment decisions., Conclusion: POLST forms generated in the hospital do transfer with patients across settings, but are often used only to document code status. POLST orders appeared largely consistent with prior treatment decisions. Further research is needed to assess the quality of POLST decisions.
Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature
(Wiley, 2015-02) Hickman, Susan E.; Keevern, Elisabeth; Hammes, Bernard J.; IU School of Nursing
The Physician Orders for Life-Sustaining Treatment (POLST) form is a palliative care tool that contains standardized, actionable medical orders. It is designed to ensure that patient treatment preferences are elicited, communicated, and honored throughout the healthcare system. A systematic review of the literature was conducted to evaluate what is currently known about the POLST program and identify directions for future research. Twenty-three research studies focused on POLST use in the clinical setting were identified. A majority of studies have been conducted all or in part in Oregon, with chart review the most frequently used methodology. Research suggests that POLST is most commonly used in older, white patients who are near the end of life. A nonphysician facilitator usually prepares the POLST form for the physician to review and sign. The orders documented on POLST reflect a wide degree of individualization, with only approximately one-third of patients having orders reflecting the lowest level of treatment in all POLST form sections. Clinicians have generally positive attitudes regarding use of POLST yet report a wide range of challenges. POLST alters treatment in a way that is consistent with orders. However, evidence that POLST reflects patient or surrogate treatment preferences is lacking. Research is needed to evaluate the quality of POLST decisions, explore the experiences of patients and their surrogates, develop decision-support tools, improve clinician education, and assess the effect of POLST on care outcomes through intervention and population-based studies.

Browsing by Author "Hammes, Bernard J."

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