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POLST Project Prompts Important Conversations

A three-year improvement project resulted in increased completion rates of POLST forms.

"As an institution, Cedars-Sinai wants to ensure that the care we're providing aligns with our patients' goals, values and preferences, particularly in relation to end-of-life care. Physicians want to know that they're respecting their patients' wishes," said Edward Seferian, MD, chief patient safety officer and medical director, Medical Affairs.

To help achieve these objectives, the Cedars-Sinai Quality Council launched an initiative in 2014 aimed at improving end-of-life care.

"We knew we needed to do a better job of eliciting from patients what they wanted in relation to end-of-life care, and we knew we needed to be more effective in making those preferences available in the medical record for use by all providers," said Michael Langberg, MD, chief medical officer and the initiative's executive sponsor. "One way to do this is with the POLST form, so we launched an effort specifically focused on this form as a means of prompting these dialogues and documenting patients' wishes."

POLST is an acronym for Physician Orders for Life-Sustaining Treatment, a form designed to increase patients' control over end-of-life care and across care settings. Recognized in California since 2009, the POLST form is administered by the Coalition for Compassionate Care of California and enables patients to have frank discussions with their healthcare providers and specify their preferences in relation to CPR, artificially administered nutrition and the scope of medical interventions desired.

Printed on hot-pink paper, the form reflects the provider's clinical judgment and is signed by the patient (or a legally recognized decisionmaker in case of incapacity) and provider — which can be a physician, nurse practitioner or physician assistant. POLST forms transform patients' preferences into physician orders that are to be followed across healthcare settings.

"One of the POLST form's goals is to protect patients and preserve their preferences outside of a hospital environment," said Jaime Goldberg, clinical social worker with Supportive Care Medicine. "Increasing completion rates of POLST forms has been a focus for several years, but over the last three years we've refined and intensified that focus."

For example, two populations were targeted: patients being discharged who have a Do Not Attempt Resuscitation (DNAR) order in their hospital medical record; and patients with dementia being discharged to a skilled nursing facility.

"These aren't the only patients we've been working with. We're also focusing on patients with advanced conditions, such as cancer and other complex, life-limiting illnesses," said Seferian, associate professor of Pediatrics.

Seferian is a team leader of the improving end-of-life care initiative along with: Beth Karlan, MD, director of the Women's Cancer Program in the Samuel Oschin Comprehensive Cancer Institute and professor of Obstetrics and Gynecology; and Bradley Rosen, MD, vice president of Physician Alignment and Care Transitions and assistant professor of Medicine.

Several strategies were employed to boost completion rates of POLST forms.

"One of the most effective strategies was integrating POLST into the workflow, particularly into progression of care rounds where patients appropriate for a POLST conversation could be identified," explained Seferian. "This was a multidisciplinary effort, including social work, case management, supportive care medicine, internal medicine, nursing, surgery, transplant, the enhanced care program, bioethics, the emergency department and physician advocates."

Seferian pointed to other impactful strategies.

"Since 2014, we've been providing physician-specific POLST form completion rates annually. We also showed how they compared with their peers' POLST completion rates," said Seferian. "In many cases, physicians wanted to know which patients would have been appropriate for POLST conversations."

A CS-Link™ best-practice alert similarly helped move the POLST-form-completion needle. When a physician places a DNAR order, a Best Practice Advisory displays indicating that a POLST form should be completed for that patient.

"The first phase of the POLST effort was increasing completion rates, which has been accomplished," Seferian said. "The completion rate for patients with a DNAR order went from about 41 percent to more than 73 percent. For patients with dementia, which is a much more complex population, the completion rate was at around 45 percent and is now nearing 60 percent."

Goldberg credits rising completion rates to the combined impact of multiple strategies.

"Some strategies were very concrete, such as making sure POLST forms were available on the units. Others were more philosophical, focusing on the importance and benefits of having these conversations," Goldberg explained.

"The POLST initiative is now in sustainment mode. The next step is making sure that the care we're delivering aligns with patients' preferences," Seferian said.

For additional information, POLST forms and a FAQ sheet in multiple languages, visit the Cedars-Sinai POLST web page.

Questions about the POLST form can be directed to Supportive Care Medicine (Inpatient: 310-423-9520; Outpatient: 310-423-7500) or the Center for Healthcare Ethics at 310-423-9636.