Most of the surveyed nursing homes (84%) say they offer the POLST to all residents in all units of the facility. Since all of the surveyed facilities have short-stay rehabilitation units, this implies that the POLST is likely being offered to relatively healthy individuals with long life expectancies. While it is quite possible that most forms for short stay residents had full care orders, the POLST is not intended for use by such individuals.
Whether the POLST form should be routinely offered to all long-stay nursing facility residents is a closer question. It can be argued that nearly all long-stay nursing home patients will ultimately die while living at the facility and therefore all such residents should have end-of-life medical orders in place via a POLST. However, some long stay residents have a
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life expectancy of many years. It may be premature to offer medical orders regarding life- sustaining treatments to these individuals.
A substantial minority of nursing home residents live in the facilities for a considerable period of time. Kelly et al (2010) looked at the average and median lengths of stay for long stay residents who died while living in a nursing home between 1992 and 2006. They found that while the median length of stay was only five months, the average stay was much longer at 13.7 months. In other words, even though most long stay residents died within a few months after admission, a sizeable percentage of individuals lived much longer and thus skewed the average length of stay upwards. Indeed, the 75th percentile of the length
of stay reported by Kelly et al. for long stay patients was 20 months, and a few patients lived in the nursing home for more than five years. The existence of a substantial number of longer-lived nursing home residents was also reported in the 2004 National Nursing Home Survey. That survey found the average length of stay in a facility as of the date of the survey to be 835 days, and the median to be 463 days (Jones, Dwyer, Bercovitz, & Strahan, 2009). However, that study’s sampling design tended to overestimate longer stay residents. Similar data exists for nursing home residents with dementia. Mitchell et al. (2009) followed 323 nursing home residents with advance dementia for 18 months and found that the median length of stay was three years. It should also be noted that these residents also had a high six-month rate of mortality (25%), and many underwent burdensome interventions in the last three months of life.
The National POLST Paradigm Task Forces says on its web site that the general screening test for use of the form is to ask “would I be surprised if this person died in the next year” (Oregon Health and Science University, 2012). The Task Force also says that
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“unless it is the patient’s preference, use of the POLST Paradigm form to limit treatment is not appropriate for persons with stable medical or functionally disabling problems who have many years of life expectancy” (Oregon Health and Science University, 2012). This implies that the appropriateness of offering a POLST should be evaluated on a case by case basis. However, the National POLST Paradigm Task Force leaves the door open to offering the form universally when it includes the words “unless it is the patient’s preference” before the prohibition on offering the POLST to individuals with many years of life expectancy. How can you determine the patient’s preference for a POLST without first offering one? Similarly, the Task Force allows offering the form to persons with “serious or life- threatening illnesses” in the optional component of the POLST paradigm for mature regional and state programs. A serious illness is not necessarily one that curtails life expectancy so this language would also seem to permit providers to offer the POLST very broadly. A training video posted on the POLST. ORG web site illustrates the Task Force’s straddling of both sides of this issue. Early in the video, a healthy elder is shown taking out skis and the voice-over says that most 65-year olds are too healthy to have a POLST. Later on a speaker says that institutions can have a policy of offering the POLST to everyone (Oregon Health and Science University, 2012).
The possibility that the POLST can be used as an instrument of voluntary euthanasia is a matter of concern to critics of the form. Brugger (2011) complains that the POLST allows some individuals, “especially those with an exaggerated conception of autonomy and a repugnance for some disability or limitation” to engage in self-killing. The Catholic Bishops of Wisconsin similarly state that the POLST oversimplifies end-of-life decision making and poses a “real risk that an indication may be made on it to withhold a treatment
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that, in particular circumstances, might be an act of euthanasia” (Wisconsin Catholic Conference, 2012). The “would you be surprised” test and other language discouraging use of the POLST for individuals with many years of life expectancy may be intended to address this concern. However, the Task Force has refused to completely shut the door on the POLST being offered to individuals with many years of life expectancy.
It cannot be said that Allegheny County nursing homes who offer the POLST to all residents of the facility are in violation of the POLST paradigm. However, offering the form to relatively healthy individuals is inappropriate.