POLST Registration and Associated Outcomes Among Veterans With Advanced-Stage Lung Cancer

Abstract

Introduction:

The Oregon Physicians Orders for Life-Sustaining Treatment (POLST) Program allows patients with advanced illness to document end-of-life (EOL) care preferences. We examined the characteristics and associated EOL care among Veterans with and without a registered POLST.

Methods:

Retrospective, cohort study of advanced-stage (IIIB and IV) patients with lung cancer who were diagnosed between 2008 and 2013 as recorded in the VA Central Cancer Registry. We examined a subgroup of 346 Oregon residents. We obtained clinical and sociodemographic variables from the VA Corporate Data Warehouse and EOL preferences from the Oregon POLST Registry. We compared hospice enrollment and place of death between those with and without a registered POLST.

Results:

Twenty-two (n = 77) percent of our cohort had registered POLST forms. Compared to those without a registered POLST, Veterans with a POLST had a higher income ($51 456 vs $48 882) and longer time between diagnosis and death (223 days vs 119 days). Those with a registered POLST were more likely to be enrolled in hospice (adjusted odds ratio [aOR] = 2.37, 95% confidence interval [CI]: 1.01-5.54) and less likely to die in a VA facility (aOR = 0.27, 95% CI: 0.12-0.59).

Conclusion:

There was low submission to the POLST Registry among Veterans who received care in Veterans’ Health Administration. Veterans who had a registered POLST were more likely to be enrolled in hospice and less likely to die in a VA care setting. The POLST may improve metrics of high-quality EOL care; however, opportunities for improvement in submission and implementation within the VA exist.

Keywords

advance care planning lung cancer physician orders for life-sustaining treatment hospice enrollment location of death palliative care EOL care

Get full access to this article

View all access options for this article.

References

Steinhauser

Christakis

Clipp

McNeilly

McIntyre

Tulsky

. Factors considered important at the end of life by patients, physicians, and other care providers. JAMA. 2000;284(19):2476–2482.

Bischoff

Sudore

Miao

Boscardin

Smith

. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc. 2013;61(2):209–214.

Oregon POLST. http://oregonpolst.org/. Accessed January 2, 2019.

National POLST Paradigm. What is POLST? 2019. http://www.polst.org/about-the-national-polst-paradigm/what-is-polst/. Accessed January 2, 2019.

Schmidt

Zive

Fromme

Cook

Tolle

. Physician Orders for Life-Sustaining Treatment (POLST): lessons learned from analysis of the Oregon POLST Registry. Resuscitation. 2014;85(4):480–485.

Fromme

Zive

Schmidt

Cook

Tolle

. Association between POLST scope of treatment orders and in-hospital death in Oregon. J Am Geriatr Soc. 2014;62(7):1246–1251.

Hickman

Nelson

Moss

Tolle

Perrin

Hammes

. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011;59(11):2091–2099.

Moss

Zive

Falkenstine

Fromme

Tolle

. Physician Orders for Life-Sustaining Treatment medical intervention orders and in-hospital death rates: comparable patterns in two state registries. J Am Geriatr Soc. 2016;64(8):1739–1741.

Higginson

Sen-Gupta

GJA

. Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med. 2000;3(3):287–300.

10.

Teno

Gozalo

Triverdi

Bunker

Lima

Ogarek

. Change in end-of-life care from Medicare beneficiaries: site of death, places of care, and health care transitions in 2000-2015. JAMA. 2018;320(3):264–271.

11.

Commission on Cancer. Cancer Program Standards. Chicago, IL: American College of Surgeons; 2015.

12.

Groll

Bombardier

Wright

. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol. 2005;58(6):595–602.

13.

Fan

Gifford

Chandolu

Colantuoni

Pronovost

Needham

. The functional comorbidity index had high inter-rater reliability in patients with acute lung injury. BMC Anesthesiol. 2012;12:21.

14.

Deyo

Cherkin

Ciol

, Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–619.

15.

Oregon POLST Registry Act. House Bill 2009. Oregon Administrative Rules ch. 595, Sec. 1184. Oregon POLST Registry Act. Salem, OR: Oregon State Legislature; 2009.

16.

Sullivan

Ganzini

Lapidus

. Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system. Cancer. 2018;124(2):426–433.

17.

Gidwani

Joyce

Kinosian

. Gap between recommendations and practice of palliative care and hospice in cancer patients. J Palliat Med. 2016;19(9):957–963.

18.

Liu

Manning

Burgess

. Reliance on veterans affairs outpatient care by Medicare-eligible veterans. Med Care. 2011;49(10):911–917.

19.

Department of Veterans Affairs. Life-Sustaining Treatment Decisions: Eliciting, Documenting and Honoring Patients’ Values, Goals and Preferences. Washington, DC: VHA Handbook 1004.03; 2017.

20.

Hickman

Nelson

Moss

. Use of physician orders for life-sustaining treatment (POLST) paradigm program in the hospice setting. J Palliat Med. 2009;12(2):133–141.

21.

American Society of Clinical Oncology. ACOS’s Choosing Wisely: “Top Five” List of Recommendations. Alexandria, VA: American Society of Clinical Oncology; 2012.

22.

National Quality Forum. National voluntary consensus standard for quality of cancer care. 2009. http://www.asco.org/practice-guidelines/cancer.-care-initiatives/value-cancer-care/choosingwisely. Accessed July 27, 2018.

23.

Rickerson

Harrold

Kapo

Carroll

Casarett

. Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better? J Am Geriatric Soc. 2005;53(5):819–823.

24.

Shugarman

Lorenz

Mularski

Lynn

; RAND-Southern California Evidence-Based Practice Center. A systematic review of satisfaction with care at the end of life. J Am Geriatr Soc. 2008;56(1):124–129.

25.

Tolle

Tilden

Nelson

Dunn

. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc. 1998;46(9):1097–1102.

26.

Zive

Fromme

Schmidt

Cook

Tolle

. Timing of POLST form completion by cause of death. J Pain Symptom Manage. 2015;50(5):650–658.