August 31, 2021

Regenstrief advance care planning expert provides guidance on use of POLST forms in nursing homes

Susan Hickman, PhD, director of the Indiana University Center for Aging Research at Regenstrief Institute, provided guidance for the appropriate use of POLST forms in a new paper published in the Journal of the Society of Post-Acute and Long-Term Care Medicine (JAMDA).

POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization and ventilation, and artificial nutrition. A version of the program is used in nearly every state. It is intended for people who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition.

Dr. Hickman is a founding member of National POLST and has spent nearly two decades studying the effect of the model on end-of-life care. In “POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-term Care,” Dr. Hickman and her co-authors note that many nursing homes are using POLST with patients who are ineligible. Some facilities use it as a universal code status form to document CPR orders for all residents, which is not its intended purpose.

Among the issues with this practice are that otherwise healthy older adults may not have experience with the context of decision-making about specific interventions, and many expect to return to baseline, making it challenging to make informed decisions about the treatment options and what may be relevant to their future and unknown health conditions. In addition, POLST forms do not expire, so if someone who has a short-term rehabilitation stay is required to have a POLST form even though they are not eligible, it could resurface later when their preferences may no longer match what is on the form.

To prevent the inappropriate use of POLST, Dr. Hickman and her co-authors suggested several considerations for practice, policy and research. They recommend:

  • Assessing and identifying which nursing home residents are eligible and appropriate for POLST.
  • Using alternate approaches to document and communicate code status.
  • Reviewing and revising specific policies for code status orders and appropriate use of POLST.
  • Conducting ongoing staff training about POLST.
  • Leveraging state survey agencies and surveyors to promote appropriate POLST use.

Dr. Hickman led the successful, widely supported campaign to pass legislation authorizing the creation of Indiana’s version of the POLST form. Most recently, she testified in the Indiana General Assembly about a bill updating the state’s legal framework to ensure that an individual’s healthcare preferences are honored near the end of life. The bill became law on July 1, 2021.

She recently completed a study on POLST use in nursing homes and is actively involved in several research projects related to advance care planning.

Other authors on the paper are Karl Steinberg, M.D., CMD of California State University; John Carney, MEd of the Center for Practical Bioethics and Hillary Lum, M.D. of VA Eastern Colorado Geriatric Research Education and Clinical Center and the University of Colorado School of Medicine.

About Susan Hickman, Ph.D. 

In addition to leading the IU Center for Aging Research at Regenstrief Institute, Susan Hickman, PhD, is a professor at Indiana University School of Nursing, a professor and Cornelius and Yvonne Pettinga Chair of Aging Research at IU School of Medicine, and the co-director of the IUPUI Research in Palliative and End-of-Life Communicating and Training (RESPECT) Signature Center.

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