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Journal Highlights From the August Issue of JAMDA

        POLST Forms

        Many long-term care facilities inappropriately use POLST forms to document the cardiopulmonary resuscitation (CPR) preferences for all residents, creating the potential for their inappropriate use in healthy individuals, researchers write in a special article in JAMDA.
        Nursing homes use POLST, originally an acronym for Physician Orders for Life-Sustaining Treatment, to guide the care of geriatric patients. Based on a patient’s desires, the POLST form contains medical orders about CPR, medical interventions such as hospitalization and ventilation, and artificial nutrition. “It is signed by a medical provider as an order that is then immediately valid and actionable, so it can be followed by nursing home staff and emergency medical responders,” said lead author Susan E. Hickman, PhD, of Indiana University’s School of Nursing and School of Medicine, in an email.
        Several studies, however, have found that nursing homes often provide POLST forms to residents and surrogates without adequate information, and they do not revisit these forms when a patient’s condition has changed.
        Routine use of POLST to document code status increases the likelihood that it will be inappropriately offered to some residents — for example, younger residents and short-stay residents who are receiving post-acute rehabilitation. Also, the staff may present these POLST forms as required documentation rather than voluntary, and there may be confusion about whether to honor a POLST in an emergency.
        “POLST is intended for patients who are at risk of a life-threatening clinical event because they have a serious, life-limiting illness, including advanced frailty,” Dr. Hickman said. “This includes many nursing home patients, but not all. Admission to a nursing home is not an automatic indication that a patient is eligible or appropriate for POLST.”
        Instead, Dr. Hickman said, POLST use should always be voluntary, and a health care professional should complete the form based on a conversation with the patient (or legal representative). She and her colleagues recommend that nursing homes implement a policy that includes criteria for determining who is POLST eligible and that addresses the following:
        • How and when to fill out the form and how a medical provider will review and sign the form.
        • Where to store it in the record and how to access it in an emergency.
        • How to send a copy with the patient at the time of transfer.
        • How to update a POLST periodically, such as when the patient’s condition changes.
        • How to document code status for residents who are not POLST appropriate or do not want to have a POLST.
        “POLST is an incredibly helpful tool to help ensure person-centered care,” Dr. Hickman said. “However, in order for care to be truly person-centered, POLST orders must be based on conversations about goals, values, and the burdens and benefits of treatment. This conversation should be led by someone who has training in advance care planning facilitation, and it should involve patients, the legal representative, and other family members as much as possible to support informed, values-based decision-making.”
        Free resources are available at www.polst.org.
        Source: Hickman SE, et al. POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care [published online: May 21, 2021]. J Am Med Dir Assoc.

        End-of-Life Care Training

        Training workshops for nursing home staff are not adequate to improve nursing home residents’ end-of-life care quality or hospitalizations, according to the results of a single-blind, cluster-randomized, controlled trial in Finland.
        Led by Pauli J. Lamppu, MD, of the University of Helsinki, researchers randomized 324 individuals who had advanced illness and a likely prognosis of less than 12 months to live into two groups: an intervention group, in which the nurses and physicians caring for the patients received training in palliative and end-of-life care over four afternoons, and a control group, in which staff received the same training after the study was completed.
        Using the 15D instrument, the researchers found that health-related quality of life declined in both groups during the 24-month follow-up period. When comparing the individuals in the intervention group and the control group, the researchers found no significant differences in hospital inpatient stays (1.87 vs. 0.81 per person-year), emergency department visits (0.72 vs. 0.56 visits per person/year), hospital costs (1,748 vs. 941 euros per person/year), or mortality (52% vs. 43%).
        Facilities might improve their results by promoting advanced care planning and consulting with a palliative care specialist, the researchers said.
        Source: Lamppu PJ, et al. Effects of Staff Training on Nursing Home Residents’ End-of-Life Care—A Randomized Controlled Trial [published online: June 13, 2021]. J Am Med Dir Assoc.

        Pain and Psychosis

        A multicomponent intervention helped improve musculoskeletal pain but not associated psychosis symptoms in individuals with dementia, a study conducted in Norway found.
        Led by Torstein F. Habiger, MD, of the University of Berger, researchers conducted a secondary analysis of data from the COSMOS trial, a cluster-randomized, single-blind, controlled trial aimed at improving individuals’ quality of life.
        Researchers randomized patients from 67 Norwegian nursing home units into two groups, where 297 individuals received the COSMOS intervention (Communication, Systematic Assessment and Treatment of Pain, Medication Review, Organization of Activities, and Safety) and 248 individuals comprised the control group. The participants were evaluated at baseline and again at four months and nine months.
        They found that pain was significantly associated with symptoms of psychosis and delusion but not hallucinations. “This is important for clinicians, as it suggests that a thorough pain assessment is essential before making treatment decisions concerning psychosis symptoms,” the researchers said.
        Pain, as measured by the Mobilization Observation Behavior Intensity Dementia Pain Scale (MOBID-2), was not significantly reduced among the individuals who received the COSMOS intervention, although the individuals with dementia who received the intervention did experience less musculoskeletal pain. COSMOS had no significant effect on psychosis symptoms, as measured by the Neuropsychiatric Inventory-NH version. The intervention also had no effect on the prescription of analgesics.
        Over time, however, pain did increase in the control group and decrease in the intervention group, suggesting that these individuals may have gained some benefit from the COSMOS intervention, the researchers said, adding that further studies about treating psychosis symptoms in nursing home residents are needed.
        Source: Habiger TF, et al. Managing Pain and Psychosis Symptoms in Nursing Home Patients: Results From a Cluster-Randomized Controlled Trial (COSMOS) [published online: June 1, 2021]. J Am Med Dir Assoc.
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