Background Nursing homes throughout the United States use the Physician Orders for Life-Sustaining Treatment (POLST) form to document resident treatment preferences as medical orders. Reasons for discordance between POLST orders and current preferences were explored in the context of a larger study of POLST discordance.
Methods Nursing facility residents (n = 25) and surrogate decision-makers (n = 25) were interviewed using Respecting Choices Advanced Steps, a structured, advance care planning facilitation process, to elicit current values-based, informed preferences. Interviews were recorded, transcribed, and coded using qualitative descriptive methods.
Results Reasons for discordance between current preferences and POLST orders included changes in preferences related to new experiences, observations of other residents, new insights, a re-evaluation of goals and values, or a change in condition. Several participants indicated that discordance occurred because they learned new information or developed a better understanding about the treatment options during the interview. A few reported that the decisions recorded on POLST were influenced by others, though this was infrequent. Other participants were unable to explain the discordance because they did not recall the original conversation, or had no insight. Facility process issues including documentation errors and being asked to make decisions hastily during admission to the nursing facility also contributed to discordance.
Discussion Reasons for discordance are varied, but suggest a need for increased education, more frequent re-evaluation of treatment preferences, and improved practices in order to ensure nursing home documentation is concordant with the current, values-based informed preferences of residents.
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