State Policy Trends Linked to Goal-Concordant Care Improvement

Variances in state Physician Orders for Life-Sustaining Treatment Program (POLST) programs have impacted how patients in certain facility-based settings receive end-of-life support.

POLST orders assist clinicians in facilitating decision-making processes at the end of life. Each state has its own policies, which are designed to help ensure that treatments align with patients’ stated preferences prior to their death.

Patients in skilled nursing home settings face a greater likelihood of receiving more goal-concordant hospice care compared to others, a trend recently found to be linked to state POLST policy differences. This is according to new research published in the Journal of the American Medical Directors Association (JAMDA).

End-of-life advance care planning in nursing homes is often fragmented and unstandardized, an issue that may be rooted in state policies, said Komal Murali, an acute care registered nurse and one of the researchers. Murali is an assistant professor at the New York University (NYU) Rory Meyers College of Nursing. States with long-standing POLST programs often have lower health care costs and patient-centered care delivery compared to others, she said.

“The study found that POLST programs, particularly those that have been around for at least a few years, are associated with a higher likelihood of nursing home residents dying in place or in hospice,” Murali told Hospice News. “This suggests that these programs may be helping to lessen unnecessary hospital transfers near the end of life and the use of aggressive care that is often misaligned with the preferences of patients and families.”

The study spanned different POLST program maturity stages and their potential effects on end-of-life care and place of death among nursing home residents and hospice patients.

Included in the research was a random sample of seniors 65 and older who died between 2012 and 2018 in the United States. Roughly 74.3% of the roughly 225,149 nursing home residents had Alzheimer’s disease or dementia. More than two-thirds of the residents were women and 82.2% were white.

Following one year after the development of a POLST program, the probability of residents dying in a nursing home or with hospice care increased by 1.6%, the research found. This probability rate rose by 5.6% after five years of POLST implementation.

POLST program maturity is associated with a higher likelihood of nursing home residents dying in place or in hospice, the researchers wrote in the study. This suggests these state policies support goal-concordant care and alleviate or reduce burdensome hospital transfers near the end of life, they stated.

The relationship between POLST maturation rates and quality improvement remains unclear, Murali indicated. However, hospitalization transfers among patients in nursing home settings has been linked to poor outcomes, as well as higher costs, she stated.

Advance care planning policies can play a significant role in patient and provider satisfaction, Murali said.

“Having something like a POLST order in place can be helpful for the medical providers, for the care teams, for the nursing home teams, to all kind of have a baseline of understanding of where the individual is in terms of decision making and their goals,” she told Hospice News. “It’s whether these orders exist when someone does have a decline or an exacerbation of an illness that requires a change of care setting. That real-time decision making can be really fraught with high emotion and stress. We want to try and improve that experience for the caregiver and the patient with earlier advance care planning and documentation of preferences.”