Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA.
Division of Geriatrics, School of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA.
Am J Hosp Palliat Care. 2023 Aug;40(8):837-843. doi: 10.1177/10499091221127996. Epub 2022 Sep 26.
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.
Qualitative descriptive study using constant comparative analysis.
Nursing facilities in Indiana ( = 6) not using POLST.
Residents ( = 15) and surrogate decision-makers of residents without decisional capacity (n = 15) with discordance between current preferences and documented LST orders.
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.
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.
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.
生命维持治疗（LST）医嘱是确保生命末期偏好一致的重要沟通工具。最近的研究表明，目前的偏好与记录的 LST 医嘱之间存在令人担忧的不相符率，尤其是在没有 POLST 的护理机构。已经探讨了在使用 POLST 的机构中不相符的原因，然而，美国大多数护理机构尚未使用 POLST 表格。
使用恒比分析的定性描述性研究。
印第安纳州（=6）未使用 POLST 的护理机构。
没有决策能力的居民（=15）及其代理人与记录的 LST 医嘱之间存在偏好不相符的居民（=15）。
从病历中提取不复苏、不住院（DNH）和不插管（DNI）医嘱。使用尊重选择高级步骤模型来引出当前的偏好。使用半结构化访谈指南来探讨当前偏好与 LST 医嘱之间不相符的原因。
不相符的原因包括：（1）缺乏有关可用 LST 选项的范围、每项涉及的内容以及如何正式表达偏好的信息；（2）与机构工作人员之前没有讨论过；（3）没有记录之前表达的偏好；（4）家属参与。
表达的偏好与 LST 医嘱之间不相符的原因表明，在没有像 POLST 那样统一和系统的 LST 医嘱文档策略的机构中，这些对话可能不会发生并且/或未被记录。工作人员应该意识到，居民和代理人可能对需要策略性征集和记录的 LST 有偏好。
