The Quality of POLST Decisions in the Nursing Facility Setting

 描述(由申请人提供)：生命维持治疗医生订单(POLST)是为了克服传统方法的局限性，通过以医疗订单的形式记录治疗偏好来尊重重症老年患者的治疗偏好。这些常规命令基于POLST促进者(通常是非内科医生)和决策者(患者或缺乏决策能力的患者的合法代理人)之间的对话。POLST一旦由决策者和治疗医生签署，在修改或撤销之前一直有效。研究表明，POLST有助于记录广泛的治疗偏好，以进行或拒绝干预，其使用直接影响治疗结果。POLST被用于指导20多个州的老年患者的护理，并已被确定为首选的姑息治疗实践。它被广泛应用于护理机构和临终关怀机构，在这些地方，患者有重要的姑息治疗需求。为了确保决策质量和避免医疗差错，POLST订单必须与决策者当前的偏好一致。与PA-13-354的目标一致，该项目旨在推进老年姑息治疗的科学。我们的目标是通过确定POLST订单和决策者偏好之间的不一致程度来评估POLST决策的质量，并描述与不一致相关的可修改因素。为了实现这一目标，将对320名长期护理机构的患者或他们的代理人进行一项观察性混合方法研究，以实现以下具体目标：1)确定当前决策者(患者或代理人)治疗偏好与长期POLST订单之间的不一致程度；2)确定当前治疗偏好与长期POLST订单之间的不一致性的相关性，控制自POLST表格完成以来的天数；3)描述对当前治疗偏好与长期POLST订单之间不一致的原因的看法(S)，控制POLST表格完成后的天数；以及4)评估POLST不协调与决策质量结果之间的关系。预计研究结果将通过确定与POLST不一致相关的可修改因素来指导提前护理规划实践的改进，以指导定制决策支持工具和教育干预的发展。这些数据对于指导临床实践的改进和为州和联邦一级从事POLST立法和报销改革工作的政策制定者提供信息是必要的。

 DESCRIPTION (provided by applicant): The Physician Orders for Life-Sustaining Treatment (POLST) was developed to overcome the limitations of traditional approaches to honoring the treatment preferences of seriously ill geriatric patients by documenting treatment preferences in the form of medical orders. These standing orders are based on a conversation between a POLST facilitator (often a non-physician) and the decision-maker (patient or the legal surrogate of patients who lack decisional capacity). Once signed by the decision-maker and treating physician, POLST remains in effect until revised or revoked. Research suggests that POLST facilitates the documentation of a wide range of treatment preferences to have or decline interventions and its use directly affects treatment outcomes. POLST is used to guide the care of elderly patients in over 20 states and has been identified as a preferred palliative care practice. It is widely used in nursing facilities and hospices, where patients have significant palliative care needs. In order to ensure decision quality and avoid medical errors, POLST orders must be concordant with the decision maker's current preferences. Consistent with the goals of PA-13-354, this project is intended to advance the science of geriatric palliative care. Our objective is to evaluate the quality of POLST decisions by determining the level of discordance between POLST orders and decision- makers' preferences and describe modifiable factors associated with discordance. In order to achieve this objective, an observational, mixed-methods study will be conducted with 320 long-stay nursing facility patients or their surrogates to achieve the following specific aims: 1) Determine the level of discordance between current decision-maker (patient or surrogate) treatment preferences and standing POLST orders; 2) Identify correlates of discordance between current treatment preferences and standing POLST orders, controlling for time in days since POLST form completion; 3) Describe perceptions of the reason(s) for discordance between current treatment preferences and standing POLST orders, controlling for time in days since POLST form completion; and 4) Assess the relationship between POLST discordance and decision quality outcomes. It is expected that findings will guide improvements in advance care planning practices by identifying modifiable factors associated with POLST discordance to direct the development of tailored decision support tools and educational interventions. These data are requisite to guide improvements in clinical practice and inform policy makers working on POLST legislation and reimbursement reform at the state and federal levels.