Improving Advanced Care Planning through Physician Orders for Life-Sustaining Treatment (POLST) Expansion across the United States: Lessons Learned from State-Based Developments

Abstract

Background:

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is an effective advance care planning tool. However, barriers to implementation persist. In the United States, POLST program development occurs at the state-level. Substantial differences between states has left POLST implementation largely unstandardized. No peer-reviewed studies to date have evaluated state-based POLST program development over time.

Objective:

To assess and learn from the successes and barriers in state-based POLST program development over time to improve the reach of POLST or similar programs across the United States.

Design:

An exploratory, prospective cohort study that utilized semistructured telephone interviews was conducted over a 3-year period (2012-2015). Stakeholder representatives from state POLST coalitions (n = 14) were repeatedly queried on time-relevant successes, barriers, and innovations during POLST program development with levels of legislative and medical barriers rated 1 to 10. Interviews were transcribed and analyzed using techniques grounded in qualitative theory.

Results:

All coalition representatives reported continuous POLST expansion with improved outreach and community partnerships. Significant barriers to expansion included difficulty in securing funding for training and infrastructure, lack of statewide metric systems to adequately assess expansion, lack of provider support, and legislative concerns. Medical barriers (mean [standard deviation]: 5.0 [0.2]) were rated higher than legislative (3.0 [0.6]; P < .001).

Conclusion:

POLST programs continue to grow, but not without barriers. Based on the experiences of developing coalitions, we were able to identify strategies to expand POLST programs and overcome barriers. Ultimately the “lessons learned” in this study can serve as a guide to improve the reach of POLST or similar programs.

Keywords

advance care planning POLST advance directives palliative care end of life scope of treatment emergency medical services (EMS)

Get full access to this article

View all access options for this article.

References

Kutner

. Due process of euthanasia: the living will, a proposal. Indiana Law J. 1969;44(4). http://www.repository.law.indiana.edu/ilj. Accessed November 16, 2017.

Cranford

. Advanced directives—the United States experience. Hum Med. 1993;9(1):64–69. http://apps.webofknowledge.com.

Hickman

Hammes

Moss

Tolle

. Hope for the future: achieving the original intent of advance directives achieving the original intent of advance directives. Hast Cent Spec Rep. 2005;35(6):S26–S30. http://www.jstor.org/stable/24290047. Accessed April 25, 2019.

Bomba

Kemp

Black

. POLST: an improvement over traditional advance directives. Clevel Clin J Med. 2012;79(7):457–464.

Meier

Isaacs

Hughes

. Palliative Care : Transforming the Care of Serious Illness. 1st ed. San Francisco, CA: Jossey-Bass; 2010.

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.

Meyers

Moore

McGrory

Sparr

Ahern

. Physician orders for life-sustaining treatment form: honoring end-of-life directives for nursing home residents. J Gerontol Nurs. 2004;30(9):37–46.

Richardson

Fromme

Zive

Newgard

. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in oregon. 2014;63(4):375–383.

Sabatino

Karp

. Improving advanced illness care: the evolution of state POLST programs. AARP Reasearch Rep. 2011:1–64. https://assets.aarp.org/rgcenter/ppi/cons-prot/POLST-Report-04-11.pdf. Accessed November 14, 2017.

10.

National POLST Paradigm. National POLST Paradigm. POLST. 2015. http://polst.org/. Accessed March 1, 2015.

11.

National POLST Paradigm. National POLST Paradigm. POLST. 2019. https://polst.org/. Accessed March 1, 2019.

12.

CMS Medicare Learning Network. Advance Care Planning. Washington DC; 2018. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf. Accessed April 25, 2019.