Browsing by Author "Heim Smith, Nicholette"

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    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.
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    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.
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    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.