Nursing Facility Provider Perceptions of Appropriate Use of POLST (RP304)

Outcomes. 1. Describe the concept of appropriate Physician Orders for Life-Sustaining Treatment (POLST) use 2. Describe the hierarchical relationship between factors influencing appropriate POLST use from a socioecological perspective Importance. Physician Orders for Life-Sustaining Treatment (POLST) is a medical order form used to elicit and document treatment preferences. National POLST guidance recommends that POLST is intended for individuals at risk of a life-threatening clinical event due to life-limiting illness. Many, but not all, nursing facility residents meet these criteria, yet there is evidence that POLST is used more widely in some nursing facilities. This suggests providers may use different criteria in assessing which nursing facility residents are appropriate for POLST. Objective. Describe provider perceptions of appropriate POLST use in the nursing facility. Methods. Nursing facility medical providers were identified through state POLST contacts. A semistructured interview guide was used to elicit provider perceptions of appropriate POLST use. Interviews were digitally recorded and transcribed. Rapid qualitative analysis was performed to code data and identify themes. Results. Participants included 27 nursing facility providers (20 MD/DOs, 6 APRNs, 1 PA) from 14 POLST-using states. Participant perceptions of themes relating to appropriate POLST use are organized using the socioecological framework: (1) Individual level: Residents at risk for burdensome interventions; residents with a poor prognosis or declining trajectory. (2) Interpersonal level: Family prefers limits on treatment (i.e., do not hospitalize, DNR, hospice care). (3) Organizational level: nursing facility policy and related clinical practices. (4) Public policy level: state law or surveyor interpretation of state law or regulation for all admitted residents. A subgroup of providers noted that "everyone" is appropriate, regardless of patient health status. Conclusion(s). Findings suggest that a hierarchical set of factors influence perceptions of appropriate POLST use. This suggests that state or facility-level requirements for POLST reduce autonomy in decision making and may contradict the recommended national POLST guidance for appropriate use of POLST in an intended patient population. Impact. Findings suggest that multilevel factors other than resident health status and preferences drive potentially inappropriate POLST use.