Thursday, October 27, 2011

Advance Directives Cut Unwanted Hospitalizations

Informed Patient: Advance Directives Cut Unwanted Hospitalizations - Health Blog - WSJ

Informed Patient: Advance Directives Cut Unwanted Hospitalizations

By Laura Landro

Frail elderly patients who have advance directives through a program to communicate treatment preferences have fewer unwanted hospitalizations, according to a new study published online in the Journal of the American Geriatrics Society.

The program uses a form known as POLST — Physician Orders for Life-Sustaining Treatment — which allows patients to document their preferences about certain treatments. Signed by both patient and doctor, the form spells out choices including whether a patient wants to be on a breathing machine or feeding tube.

The program launched in Oregon almost 20 years ago, but remains controversial to some groups that feel life-sustaining treatment should always be administered.

Efforts to expand use of the forms, currently in use in about 14 states, with about 20 programs in development, were the subject of an Informed Patient column earlier this year.

The new study was designed to assess whether treatments provided were consistent with what was documented on the POLST form. A review of the forms for 870 living and deceased patients found that orders about resuscitation were honored 98% of the time, and orders to limit medical interventions were honored 91.1% of the time.

When patients identify treatments they don’t want, the forms direct clinicians to focus on enhancing comfort if needed. Near the end of life, 24% of POLST orders were rewritten to reflect a change of preferences, primarily for comfort-focused care.

Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health & Science University, and one of the study’s authors, tells the Health Blog that the study found that in cases where wishes were not respected, “there was a good reason most of the time.”

For example, patients were sent to the hospital if they fell and broke a hip because surgical procedures were required to control pain. “We of course would set a fracture or sew up a wound,” Tolle says. “The wonderful news is that there isn’t a sense of patients refusing care and so they are neglected,” she adds. “Instead they are getting appropriate comfort measures when that is what is indicated.”

Tolle says the next step is changing the culture of health care, where end-of-life decision making is still a fraught issue and interventions may be standard procedure even in the frail and elderly. “It’s one thing to change the law to make it possible to use POLST effectively and another to have it offered to every patient in a nursing home or hospice care,” she says.

The POLST study adds to the growing debate over end of life care. Another recent study published last month in the New England Journal of Medicine found that health-care transitions — such as a move from one nursing home to another — in the last months of life can be burdensome and potentially of limited benefit for patients with advanced cognitive and functional impairment.

The study of 474,829 nursing home residents identified close to 20% had at least one such transition, including multiple hospitalizations in the last 90 days of life. Blacks, Hispanics and those without advance directives were at increased risk.

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