Callahan (1989) warned of a “klutz factor,” referring to what happens to movements and practices “when they are taken out of the hands of the first pioneers, who act carefully and thoughtfully after due deliberation, and are put the hands of very large numbers of people who may not approach them with the same care.” This concern has not escaped some members of the National POLST Paradigm Task Force. Two members have cautioned that if institutions using the POLST do not take steps to insure that the form is used as intended, it can “morph into another trampling of patient autonomy” (Bomba & Sabatino, 2009).
The aim of the research reported in this dissertation is to follow up on the concern that the POLST is being used in medical institutions in a way that is different from the way
72
the form is intended for use by its designers. The research addresses hypothesis six (H6) outlined above. The research is exploratory in nature.
Most of the studies touching on POLST implementation ask whether the appropriate signatures were include on the completed POLST forms and/or whether there was an indication on the forms with whom the orders were discussed. Hickman et al. (2004) conducted a chart review of 355 POLST forms in seven nursing homes and looked at whether the forms contained the required physician or nurse practitioner signature, the optional resident or surrogate signature, and a specification with whom the orders were discussed. Hickman et al. (2009) looked for the presence or absence of the same signatures and specification in a hospice setting. Hickman et al. (2010) included a check for resident or surrogate signatures as part of their study comparing treatments of nursing facility residents with or without a POLST.
There has been less research focusing on the procedures used by medical facilities to obtain completion of the form. Myers, Moore, McGrory, Ocn, and Ahern (2004) asked two residents and five surrogates how the POLST form was introduced to them. They also asked staff at four nursing homes about training, informed consent procedures, and institutional policies regarding the POLST form. Caprio, Robbins, and Roberts (2012) asked twelve health professionals in two North Carolina nursing homes about the timing for completion of the POLST and who helps with its completion. They also asked about the procedure for introducing the form to residents and whether the respondents were aware of review requirements. Sabatino and Karp (2011) asked knowledgeable informants to about how the form was being used in 12 states, but did not study any particular treatment setting. The
73
California survey by Wenger et al. (2012) included questions about staff education and difficulties encountered when completing a POLST.
The research conducted for this dissertation asked about signatures and other procedural matters, but also inquired about whether the POLST was presented to individuals as required, recommended or optional, who was offered the form, and whether there was compliance with State law requirements regarding surrogate authority to make treatment selections. No previous study has looked at these issues. Nursing homes were selected as focus of the research because the POLST is widely used in that setting and, since much of the existing research deals with nursing home use, the research results can be viewed in the context of the literature rather than standing alone. H6 was selected as the focus of the research because the results could be scientifically meaningful in the context of the existing literature. Additionally, an investigation of POLST procedures in nursing homes via a survey of facility personnel is a manageable project for a doctoral dissertation. I considered focusing upon H1 and the authenticity of resident preferences since research on this issue is urgently needed. However, the complexity of that project made it infeasible for me.
Data collection was conducted in Allegheny County, Pennsylvania and was limited to nursing homes participating in the POLST program. Allegheny County was selected for convenience of the researcher, but also because the county has many characteristics that make it a good site for an exploratory inquiry into how the POLST is being used. The county has a program for nursing homes that has been in operation since 2000. This program was also developed under the general guidance of a National POLST Paradigm Task Force member located in Pittsburgh, and therefore the purpose and method of the POLST paradigm
74
were often communicated to participating facilities by a person directly involved with its development.
Nursing homes using the POLST in the county were identified through a listing obtained from the member of the National POLST Paradigm Task Force located in Pittsburgh. That Task Force member partnered with a major health insurer and the University of Pittsburgh Institute on Aging to promote use of the form in nursing homes, hospitals, hospices, and retirement communities. Twenty-four nursing facilities were identified as using the POLST form for their residents.
The researcher developed a survey form covering a number of aspects of POLST use in nursing homes, including questions asking about compliance with the required and recommended safeguards for use identified by the National POLST Paradigm Task Force. The survey was designed for face-to-face administration with a respondent designated by the nursing facility. Survey questions relating to procedural safeguards were all in the multiple choice format covering all possible choices including “other” or “uncertain” responses. The survey script read to respondents encouraged them to provide additional information if the suggested responses did not adequately capture the facility’s practices. A copy of the survey form is an appendix to this dissertation.
A draft of the survey form and accompanying instructions was submitted for expert review to three current or past members of the National POLST Paradigm Task Force. Comments from these individuals were incorporated into the survey form. The survey was pre-tested at three Allegheny County nursing homes and revised again in response to issues revealed during the testing phase. The final survey form was submitted to the Institutional Review Board of the University of Pittsburgh and was approved.
75
Introductory letters were sent to all of the identified POLST participating nursing facilities in Allegheny County. These letters were followed up by a telephone call to each facility seeking the names of the individuals responsible for the POLST program at the facility. The identified individuals always included either a social services staff member or the director of nursing. Face to face interviews were successfully conducted at 19 of the 24 facilities by the researcher.
The interviews took about thirty minutes each and were conducted over a four month period beginning in April 2010. Survey respondents were assured confidentiality during the introductory script reading. The survey form did not identify either the facility or the respondent by name. The response rate was 79%. The results of the survey were coded onto an Excel spreadsheet at the close of the field work, and were tabulated by hand. Three articles were developed using the data. These articles follow. As of December 2012, article one is being considered for journal publication in a revised form. The two other articles may be submitted for publication at a future date.
76
4.0 ARTICLE ONE – THE PHYSICIAN ORDERS FOR LIFE SUSTAINING