Jeanette Ruiz, DNP, APRN, FNP-C

Abstract:

Background: Many advanced practice clinicians (APCs) do not receive training on how to engage in discussions regarding the Physician Orders for Life-Sustaining Treatment (POLST) form with chronically ill geriatric patients, leading to delays and communication gaps that may result in misalignment between medical interventions and end-of-life (EOL) preferences. The POLST form is a tool intended to foster meaningful discussions among patients, families, and healthcare providers, translating EOL care preferences into actionable medical orders that align with patients’ values. Use of the POLST form has been shown to enhance EOL care quality, reduce unnecessary interventions, and support swift decision-making in the setting of cardiopulmonary arrest. Evidence indicates that early advance care planning increases POLST completion rates, referrals to palliative care, and use of hospice services. Targeted advance care planning education and training have been shown to enhance clinicians' comfort and knowledge, enabling them to initiate and navigate these sensitive conversations more effectively. Objectives: This intervention aimed to enhance APCs knowledge and comfort in discussing POLST forms for community-dwelling geriatric patients with chronic illnesses, to improve documentation of POLST form discussions, to increase the completion rate and uploading of POLST forms to the electronic medical record (EMR), and to boost referrals to either palliative care or hospice for eligible patients. Methods: This quality improvement project employed a single-group pretest-posttest design. A one-hour, online training, featuring didactic instruction, role-play, and debriefing was implemented for APCs delivering home-based care through a Medicare Advantage insurer in Northern and Southern California. Pre- and post-intervention surveys assessed knowledge and comfort, while retrospective chart reviews assessed documentation of POLST forms and referrals to palliative care and hospice services. Results: Thirty-seven APCs completed all three surveys. EMR data were analyzed for 43 eligible APCs. Palliative care referrals and hospice referrals were analyzed from 45 APCs who consented to participate. At three months, modest improvements were observed in POLST knowledge and comfort as well as in referrals to palliative care and referrals to hospice. Statistically significant improvements were observed in several key areas, including documentation status of POLST completion (p < 0.001), discussions (p < 0.001), and uploads (p < 0.001); knowledge and understanding of hospice (p = 0.023) and palliative care (p = 0.002); perceived preparedness to discuss POLST (p = 0.02); comfort in assisting patients and families with EOL conflicts (p = 0.04); comfort in addressing religious and cultural perspectives regarding EOL (p < 0.001); and the use of structured communication frameworks (p < 0.001). Conclusion: The findings demonstrated that targeted POLST education, supported by online hands-on training, effectively improved clinician knowledge, comfort, and documentation. By leveraging existing resources and integrating POLST into standard workflows, the project demonstrated a scalable advance care planning intervention.

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