Browsing by Author "Sudore, Rebecca L."

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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.
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    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.
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    A Research Agenda for Communication Between Health Care Professionals and Patients Living With Serious Illness
    (AMA, 2017-09) Tulsky, James A.; Beach, Mary Catherine; Butow, Phyllis N.; Hickman, Susan E.; Mack, Jennifer W.; Morrison, R. Sean; Street, Richard L., Jr.; Sudore, Rebecca L.; White, Douglas B.; Pollak, Kathryn I.; School of Nursing
    Importance Poor communication by health care professionals contributes to physical and psychological suffering in patients living with serious illness. Patients may not fully understand their illness, prognosis, and treatment options or may not receive medical care consistent with their goals. Despite considerable research exploring the role of communication in this setting, many questions remain, and a clear agenda for communication research is lacking. Observations Through a consensus conference and subsequent activities, we reviewed the state of the science, identified key evidence gaps in understanding the impact of communication on patient outcomes, and created an agenda for future research. We considered 7 broad topics: shared decision making, advance care planning, communication training, measuring communication, communication about prognosis, emotion and serious illness communication, and cultural issues. We identified 5 areas in which further research could substantially move the field forward and help enhance patient care: measurement and methodology, including how to determine communication quality; mechanisms of communication, such as identifying the specific clinician behaviors that patients experience as both honest and compassionate, or the role of bias in the clinical encounter; alternative approaches to advance care planning that focus on the quality of serious illness communication and not simply completion of forms; teaching and disseminating communication skills; and approaches, such as economic incentives and other clinician motivators, to change communication behavior. Conclusions Our findings highlight the urgent need to improve quality of communication between health care professionals and patients living with serious illness through a broad range of research that covers communication skills, tools, patient education, and models of care.
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    The care planning umbrella: The evolution of advance care planning
    (Wiley, 2023) Hickman, Susan E.; Lum, Hillary D.; Walling, Anne M.; Savoy, April; Sudore, Rebecca L.; School of Nursing
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    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.
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    Use of the Physician Orders for Scope of Treatment Program in Indiana Nursing Homes
    (Wiley, 2018-07) Hickman, Susan E.; Sudore, Rebecca L.; Sachs, Greg A.; Torke, Alexia M.; Myers, Anne L.; Tang, Qing; Bakoyannis, Giorgos; Hammes, Bernard J.; School of Nursing
    OBJECTIVES: To assess the use of the Indiana Physician Orders for Scope of Treatment (POST) form to record nursing home (NH) resident treatment preferences and associated practices. DESIGN: Survey. SETTING: Indiana NHs. PARTICIPANTS: Staff responsible for advance care planning in 535 NHs. MEASUREMENTS: Survey about use of the Indiana POST, related policies, and educational activities. METHODS: NHs were contacted by telephone or email. Nonresponders were sent a brief postcard survey. RESULTS: Ninety-one percent (n=486) of Indiana NHs participated, and 79% had experience with POST. Of the 65% of NHs that complete POST with residents, 46% reported that half or more residents had a POST form. POST was most often completed at the time of admission (68%). Only 52% of participants were aware of an existing facility policy regarding use of POST; 80% reported general staff education on POST. In the 172 NHs not using POST, reasons for not using it included unfamiliarity with the tool (23%) and lack of facility policies (21%). CONCLUSION: Almost 3 years after a grassroots campaign to introduce the voluntary Indiana POST program, a majority of NHs were using POST to support resident care. Areas for improvement include creating policies on POST for all NHs, training staff on POST conversations, and considering processes that may enhance the POST conversation, such as finding an optimal time to engage in conversations about treatment preferences other than a potentially rushed admission process.