title: Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents.
abstract: Physician Orders for Life-Sustaining Treatment (POLST) is a tool that facilitates the elicitation and continuity of life-sustaining care preferences. POLST was implemented in California in 2009, but how well it disseminated across a large, racially diverse population is not known and has implications for end-of-life care.
  
  
  
  To evaluate the use of POLST among California nursing home residents, including variation by resident characteristics and by nursing home facility.
  
  
  
  Observational study using California Minimum Data Set Section S.
  
  
  
  A total of 296,276 people with a stay in 1,220 California nursing homes in 2011.
  
  
  
  The proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; change in POLST use during 2011; and POLST completion and unsigned forms within nursing homes.
  
  
  
  During 2011, POLST completion increased from 33 to 49 % of California nursing home residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status. There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. Variation in POLST completion among nursing homes far exceeded that attributable to resident characteristics with 40 % of facilities having ≥80 % of long-stay residents with a completed POLST, while 20 % of facilities had ≤10 % of long-stay residents with a completed POLST. Thirteen percent of nursing home residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid.
  
  
  
  Statewide nursing home data show broad uptake of POLST in California without racial disparity. However, variation in POLST completion among nursing homes identifies potential areas for quality improvement.
authors.affiliation: David Geffen School of Medicine at UCLA, Division of Geriatrics, 10945 Le Conte Ave., Suite 2339, Los Angeles, CA, 90095-1687, USA. lajennings@mednet.ucla.edu.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Jennings
authors.affiliation: David Geffen School of Medicine at UCLA, Division of General Internal Medicine and Health Services Research, 911 Broxton Ave, Los Angeles, CA, 90024, USA.
authors.forename: David
authors.initials: D
authors.lastname: Zingmond
authors.affiliation: David Geffen School of Medicine at UCLA, Division of General Internal Medicine and Health Services Research, 911 Broxton Ave, Los Angeles, CA, 90024, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Louie
authors.affiliation: David Geffen School of Medicine at UCLA, Division of General Internal Medicine and Health Services Research, 911 Broxton Ave, Los Angeles, CA, 90024, USA.
authors.forename: Chi-Hong
authors.initials: CH
authors.lastname: Tseng
authors.affiliation: Coalition for Compassionate Care of California, Sacramento, CA, USA.
authors.forename: Judy
authors.initials: J
authors.lastname: Thomas
authors.affiliation: California HealthCare Foundation, Oakland, CA, USA.
authors.forename: Kate
authors.initials: K
authors.lastname: O'Malley
authors.affiliation: David Geffen School of Medicine at UCLA, Division of General Internal Medicine and Health Services Research, 911 Broxton Ave, Los Angeles, CA, 90024, USA. nwenger@mednet.ucla.edu.
authors.forename: Neil S
authors.initials: NS
authors.lastname: Wenger
mesh_terms: D000203:Activities of Daily Living; D032722:Advance Care Planning / Q000458:organization & administration*; D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D002140:California; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008134:Long-Term Care / Q000458:organization & administration; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes / Q000458:organization & administration*; D057240:Patient Preference; D058996:Quality Improvement; D016414:Resuscitation Orders; D013727:Terminal Care / Q000458:organization & administration*
keywords: end-of-life care; long-term care; nursing home; quality improvement