Abstract
A Provider Orders for Life-Sustaining Treatment (POLST) document transforms medical wishes for end-of-life care into actionable medical orders. This study was conducted to assess the extent of POLST implementation amongst nursing facilities in Hawai‘i. We performed a telephone survey . The survey instrument included questions about advance care planning processes, POLST training procedures, and implementation of the POLST paradigm. Data were collected in July 2014, the month POLST signatory capacity expanded to include Advance Practice Registered Nurses (APRNs). Of the 39 nursing facilities contacted, 23 (59%) responded. All but one facility had a POLST program in place. Social workers and nursing staff usually held the POLST discussions. Of the 23 responding facilities, 13 (57%) had at least one APRN provider, and 8 had APRNs involved in POLST discussions. In all but one instance, APRNs were also already signing the document. The percentage of residents with completed POLST forms per facility was reported to be over 50% for 20 out of 23 (87%) of responding nursing facilities with 10 (43%) reporting achieving 100% implementation rates. Training seminars and online educational materials were the main methods for training staff, with social workers and nurses being the focus for training. The results of this study demonstrate significant penetration of the Hawai‘i POLST program into the nursing home community. Most nursing facilities required staff to undergo POLST training. Some facilities reported APRNs were already involved in signing the POLST form, only weeks after their signatory capacity was enacted.
Introduction
The Provider Orders for Life-Sustaining Treatment (POLST) form is a standardized, bright green form designed to translate patient preferences for end-of-life care into actionable medical orders and to convey those orders across different settings of care. The portability and range of treatment options make the POLST form particularly useful for nursing home patients.1 Previous work has demonstrated the effectiveness of the POLST paradigm in ensuring end-of-life preferences are honored.2,3
States like Oregon, where the POLST program is more established, have demonstrated high rates of penetration of the POLST paradigm.4 However nodata are yet available regarding the adoption of the POLST paradigm in nursing facilities in Hawai‘i. Hawai‘i was an early adopter of the POLST paradigm, becoming just the eighth state in the United States to have a nationally endorsed program. As of July 1st 2014, the Hawai‘i statute governing POLST expanded signatory authority in Hawai‘i beyond physicians to include Advance Practice Registered Nurses (APRNs). This expansion in signatory authorityprompted the present study. The objectives of this study were to assess the extent of POLST paradigm implementation among nursing facilities in Hawai‘i, as well as to assess the training and involvement of APRNs in particular in the POLST paradigm.
Methods
The research design was a cross-sectional telephone survey conducted in July 2014 using a modified instrument (Appendix 1).5 The instrument included questions on facility size, advance care planning processes, POLST training procedures and percentage of residents who had a completed POLST form. A list of registered nursing facilities in the State of Hawai‘i was obtained from the Department of Health website.6 The nursing facilities surveyed ranged in size from 10 to 254 licensed beds. The administrator of each nursing home was contacted via telephone to participate in the survey. Up to three attempts were made to contact each administrator. Participation was voluntary and consent was obtained verbally via telephone at the time of the survey interview. Non-respondents and administrators who declined to participate were excluded from analysis. Survey responses were de-identified and no information was attributable to any individual facility. The descriptive results were then tabulated and analyzed.
The study was conducted according to United States and International standards of Good Clinical Practice, applicable government regulation and institutional research policies and procedures. The protocol was approved by the Queen's Medical Center Research and Institutional Review Committee and University of Hawai‘i Human Subjects Committee.
Results
Some 39 registered nursing facilities were called in July 2014 to participate in the study, of which 23 responses were obtained, resulting in a 59% response rate.
1. Implementation of POLST
Of the 23 facilities surveyed, all but one (96%) had a POLST paradigm program in place. That single facility cited having insufficient social workers to implement a POLST paradigm program at the present time, but did describe an intentionto begin a program in the near future. Over half of the facilities had a POLST program in place for more than 2 years (Table 1). The resident POLST completion rate reported by each facilityis shown in Table 2. Of the 23 facilities surveyed, 20 (87%) reported an implementation rate of greater than 50% and 10 facilities (43%) reported 100% implementation rates. All facilities surveyed stated that their goal was to obtain POLST forms for 100% of their residents.
Table 1.
POLST Implementation by Facility
| Duration of POLST program | Number of Facilities |
| None | 1 |
| < 6 months | 1 |
| 6 months to 1 year | 5 |
| 1 to 2 years | 5 |
| > 2 years | 11 |
Table 2.
Resident POLST Completion Rate by Facility
| Residents with completed POLST (estimates) | Number of Facilities |
| 0–25% | 3 |
| 56–50% | 0 |
| 51–75% | 5 |
| 76–99% | 5 |
| 100% | 10 |
2. POLST Training
Facilities reported that social workers and nursing staff were most frequently involved in providingPOLST counseling for residents (Table 3). Less often physicians and APRN's provided POLST counseling and only one facility reported case managers had this role.
Table 3.
Provider who typically does advance care planning with residents
| Provider Type | Number of Facilities |
| Social service | 20 |
| Nursing | 16 |
| Physicians | 12 |
| APRN provider | 8 |
| Case manager | 1 |
Social workers and nurses were the focus for staff being trained (Table 4). Only 2 facilities trained all staff. However, most facilities when questioned, did mention that all staff should be trained, rather than focusing on a specific group.Of the 13 facilities that reported having APRN providers, 8 reported APRNs were involved in POLST counseling and 3 reported APRNs were included in POLST training.
Table 4.
Providers who are trained on POLST
| Provider Type | Number of Facilities |
| Social service | 19 |
| Nursing | 22 |
| Physicians | 2 |
| APRN provider | 3 |
| Case manager | 1 |
| All staff | 2 |
The training methods used by nursing facilities varied (Table 5). Most facilities (60%) held training seminars on the POLST paradigm program. Online materials such as those found on the Kokuamauwebsite7 were often used, as well as facility-specific material. Videos, specifically the ACP Decisions videos produced by the Nous Foundation were also used by many facilities. Fewer facilities reported making use of POLST conferences produced by Hawai‘i Medical Service Association, the largest health insurance provider in Hawai‘i.
Table 5.
POLST training method used
| Training Method | Percentage Used |
| Training seminar | 60% |
| Online material | 39% |
| Facility material | 35% |
| Videos | 30% |
| POLST conference | 13% |
Discussion
We found that there is good penetration of the Hawai‘i POLST paradigm program into the nursing home community in Hawai‘i. Nearly all responding facilities (96%) had a POLST paradigm program in place and nearly half (48%)reported having their program in place for over 2 years. Furthermore, most facilities (87%) had over 50% resident POLST completion rates. This finding is encouraging compared to POLST implementation rates nationally. A cross-sectional sample study conducted in 2004 showed that fewer than 1in 5 US nursing homes participated in end-of-life programs, with the largest proportion participating in POLST (13.3%).8 Hawai‘i also does well when compared to states where the POLST paradigm is more established. In Oregon 71% of facilities reported using the POLST for at least half of their residents.4 In California, 54% of nursing home residents were estimated to have a POLST.9
The apparent success of the Hawai‘i POLST program could be attributed to several factors. We found that most nursing facilities in Hawai‘i required staff to undergo POLST training. This could increase awareness and enable discussions of POLST with nursing home residents. Furthermore, Hawai‘i Medical Service Association (HMSA), which is the leading health insurance provider in the state has been implementing measures to incentivize advance care planning. In addition, HMSA has been conducting POLST seminars which some facilities claimed they were using for training staff on POLST. Finally, we found that APRN providers were already involved in signing the POLST form, and this was within weeks of their signatory capacity being enacted. Not all nursing facilities had APRN providers (only 13 of the 23 had them); hence the numbers of APRNs involved in POLST discussions were lower than might have been expected.
Strengths and Limitations
This is the first statewide study on the POLST paradigm to be conducted in Hawai‘i. The study included nursing facilities on the islands of Hawai‘i, Kaua‘i, Maui, and O‘ahu. As the first study on POLST in the state of Hawai‘i, it provides valuable data on the penetration of the POLST program so far. These findings can serve as a baseline for comparison by future surveys to measure progress of the POLST paradigm in Hawai‘i. The limitations of this study includethe potential for response bias as nursing homes with POLST programs in place may have been more likely to participate. In addition, the responses obtained were based on estimates from an individual at each facility and could not be verified by chart review.
Future Directions
The POLST paradigm functions optimally when all settings for care actively participate. Successful expansion to appropriate populations at high risk for critical illness is needed across these settings in Hawai‘i including primary care andacute care settings in addition to the long-term care setting studied here.Recent pay for quality initiatives may help advancePOLST implementation rates across settings. Future studies will be needed to assess and monitor the progress of the POLST paradigm program across all settings of care.
Promotion of greater knowledge and awareness among the public and healthcare providers about advance care planning in general, and the POLST paradigm in particular, is important in advancing POLST implementation. Education and training on the POLST paradigm should be made widely available. This study highlighted a need to focus on advancing education and training on the POLST paradigm for APRN providers in Hawai‘i given their new signatory role.
Finally, the results of this study showing the early successful adoption of the POLST paradigm program in Hawai‘i's long-term care community may lend support to the development of a state-wide POLST registry in Hawai‘i to promote timely access to POLST forms.
Appendix 1: Polst Nursing Facility Questionnaire
Thank you for considering participating in this brief survey on Provider Orders for Life-Sustaining Treatment (POLST). I am gathering information from facilities to evaluate the spread of the POLST program throughout Hawai‘i. We expect the information gathered to help in advancing Hawai‘i's POLST program statewide. All data will be de-identified for analysis and no information will be attributable to any individual facility. Your participation in this survey is completely voluntary. If you agree to participate, the survey would typically take 5 to 10 minutes for us to complete.
| General POLST Information | |
| Facility Name | |
| Facility contact/location | |
| Size of facility | □<50 beds □ 50 to 150 beds □> 150 beds |
| Have you implemented POLST in your facility? | □ No □<6 months □ 6 mo – 1 year □1–2 years □> 2 years |
| If you have not implemented, when are you planning to implement POLST to your facility? | □<3 months □<6 months □6 mo–1year □1–2 years □ Not planning. What are the barriers? |
| What forms do you use to ensure patient wishes are followed regarding life sustaining treatments (check all that apply) | □ Living Will/ Advance Directive □ Facility Form □ POLST □ None |
| Who typically does advance care planning with residents? (check all that apply) | □ Physician □PA □ Social Service □ Nursing □ Case managers □ APRN |
| POLST Implementation and Training | |
| How widely is POLST implemented in your facility? | □ 0–25% □ 26–50% □ 51–75% □76–99% □ 100% |
| What is the total percent of the facility that POLST is planned to be implemented | □ 0–25% □ 26–50% □ 51–75% □76–99% □ 100% |
| How have you implemented POLST in your facility? (check all that apply) | □ Training seminar □ Facility communications □ Provide professional education material □ Mandatory Curriculum □ Web/Online training □ Provide patient/resident education material |
| What training materials are you using? (check all that apply) | □ POLST conference training material □ Facility materials □ Web download material □ Other: |
| Who is being trained? (check all that apply) | □All staff □ Physician □ Advanced Practice Nurse □ Social workers □ Case managers □ Clergy □ Admissions □ Other: |
| Are there APRN providers, if yes: role in POLST | □ None □ Education □ Counseling patient/resident □ Signing the POLST form |
| Permission to send relevant information via email related to POLST education? | □ Yes □No If yes, contact information: |
Footnotes
Disclaimer: The findings of this study do not necessarily represent the views of The Queen's Medical Center or University of Hawai‘i.
Conflict of Interest
None of the authors identify any conflict of interest.
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