Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA.
Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.
J Am Geriatr Soc. 2021 Jul;69(7):1865-1876. doi: 10.1111/jgs.17095. Epub 2021 Mar 24.
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.
To describe POLST preference concordance and identify factors associated with concordance.
Chart reviews to document existing POLST orders and interviews to elicit current treatment preferences.
POLST-using nursing facilities (n = 29) in Indiana.
Nursing facility residents (n = 123) and surrogates of residents without decisional capacity (n = 152).
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.
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).
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.
POLST 被广泛用于记录护理院居民的治疗偏好作为医嘱，但目前尚不清楚之前完成的 POLST 医嘱与当前偏好的吻合程度（一致性），以及哪些因素与之相关。
描述 POLST 偏好的一致性，并确定与一致性相关的因素。
记录现有 POLST 医嘱的图表审查和获取当前治疗偏好的访谈。
印第安纳州使用 POLST 的护理院（n=29）。
护理院居民（n=123）和无决策能力居民的代理人（n=152）。
通过比较复苏、医疗干预和人工营养的现有 POLST 医嘱与当前治疗偏好来确定一致性。以舒适为重点的 POLST 包含不复苏、舒适措施和无人工营养的医嘱。
总体而言，有 55.7%（123/221）的居民和 44.7%（152/340）的代理人参与（总 n=275）。POLST 一致性为 44%，但以舒适为重点的 POLST 一致性更高（68%），而非以舒适为重点的 POLST 一致性更低（27%）（p<0.001）。在未调整的分析中，居民年龄增加（OR 1.04，95%CI 1.01-1.07，p<0.01）、认知功能更好（OR 1.07，95%CI 1.02-1.13，p<0.01）、代理人作为决策者（OR 2.87，OR 1.73-4.75，p<0.001）和以舒适为重点的 POLST（OR 6.01，95%CI 3.29-11.00，p<0.01）与一致性相关。在调整后的多变量模型中，只有现有的以舒适为重点的 POLST 与更高的 POLST 一致性几率相关（OR 5.28，95%CI 2.59-10.73，p<0.01）。
不到一半的 POLST 表格与当前偏好一致，但当医嘱反映以舒适为重点的护理偏好时，POLST 一致的可能性高出五倍以上。研究结果表明，迫切需要提高护理院使用 POLST 的质量，并将其重点用于具有稳定舒适偏好的居民。
