Browsing by Author "Tolle, Susan W."

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    Assessing Evidence for Physician Orders for Life-Sustaining Treatment Programs
    (JAMA, 2016-06) Tolle, Susan W.; Moss, Alvin H.; Hickman, Susan E.; IU School of Nursing
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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.
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    Physicians' and nurses' perspectives on increased family reports of pain in dying hospitalized patients
    (2000) Hickman, Susan E.; Tolle, Susan W.; Tilden, Virginia P.
    Many indicators suggest that care of the dying in Oregon has been improving over the past decade. However, results from a recent study suggest that one aspect of care of the dying, pain management, may be worsening. In late 1997, family reports of moderate and severe pain in dying hospitalized patients increased from 33% to 57%. This occurred during a volatile time in the Oregon political climate associated with events surrounding a second vote on physician-assisted suicide. In order to better understand the observed increase better, a statewide sample of physicians and nurses was surveyed to obtain their opinions about factors that may have contributed to the increased family reports of moderate and severe pain in dying hospitalized patients. Seventy-nine percent of respondents endorsed two or more factors as partial explanations. These factors include an increase in family expectations about pain management (endorsed by 96%), decreased physician prescribing (endorsed by 66%), and reduced nurse administration of pain medication (endorsed by 59%). Physicians who thought reduced physician prescribing was a partial factor rated fears of the Board of Medical Examiners and the Drug Enforcement Administration as the most likely explanations for decreased prescribing. More research is needed to better understand family expectations for end-of-life care, fears of investigation, and pain medication practices.
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    Trends in opioid use over time: 1997 to 1999
    (2004-02) Tolle, Susan W.; Hickman, Susan E.; Tilden, Virginia P.; Bubalo, Joseph S.; Fromme, Erik K.
    Substantial resources have been spent to improve pain control for dying patients, and increased opioid administration has been presumed. Oregon has been a consistent leading state in per capita use for morphine for the past 10 years, as recorded by the Automation of Reports and Consolidated Orders System (ARCOS). Health policy experts, extrapolating from World Health Organization methods, have suggested these data are indicative of the quality of end-of-life care in Oregon. To determine whether trends in opioid prescription at the state and national levels reflect increased opioid use for inpatients during the final week of life, chart reviews were conducted to record all opioid medications administered in the last week of life to 877 adult inpatients who died from natural causes between January 1, 1997 and December 31, 1999. Inpatient morphine use did not increase significantly for dying patients from 1997 to 1999. However, overall morphine use for both Oregon and the United States as measured by ARCOS data increased significantly. Comparisons revealed no significant difference between linear trends for Oregon and U.S. morphine use, but both were significantly greater than the dying inpatients. This pattern was also found for all other opioids. These findings suggest that ARCOS data do not necessarily provide information about opioid use for specific subpopulations of patients and raise questions about the meaning of observed increases in ARCOS data.
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    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.