We propose to study the effects of Physician Orders for Scope of Treatment (POST) Facilitation in a randomized controlled trial in a population of community dwelling older adults who qualify for POLST facilitation, including those with normal cognition and those with Alzheimer's Disease and Related Disorders.
The POLST paradigm, which stands for Physician Orders for Life Sustaining Treatment, was developed to address inconsistencies between care received and patient and family wishes for treatment, with an aim to increase concordant care. The POLST paradigm is nationally recognized and implemented in a number of states under different names. In Indiana, for example, it is called "Physician Orders for Scope of Treatment" (POST). Because of this, all patient facing materials will refer to POST, however, we use the terms POST and POLST interchangeably in this proposal. POLST affects delivery of medical interventions and improved concordance between patient preferences and care received. Our specific aims are: 1. To test the effect of high quality POLST Facilitation delivered in the home compared to attention control on: a.discordance between preferences for treatment and treatments received in the subsequent 12 months (primary outcome). 2. To test the effect of POLST Facilitation on intermediate outcomes including: 1. The proportion of patients with a completed POLST form in the electronic medical record within 3 months of POLST Facilitation 2. Decision quality regarding ACP as measured by the Decisional Conflict Scale, the advance care planning (ACP) Engagement Survey,and the POLST knowledge survey 3. To test the effect of a POLST Facilitation on secondary outcomes of cost and end-of-life care including: 1. Receipt of life-sustaining interventions or hospice within the 30 days prior to death, for patients who die during the year after POLST Facilitation 2. The psychological well-being (anxiety, depression,and post traumatic stress) of surrogate decision makers after the patient's death 3. The cost effectiveness of POLST Facilitation for the prevention of ICU admissions and hospitalizations
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
SINGLE
Enrollment
389
Advanced steps is initiated as a component of quality end-of-life care for frail elders and those whose death in the next 12 months would not be unexpected. The AS planning conversation is focused on goals of care to make timely, proactive, and specific end-of-life decisions. Ideally, these decisions are converted into medical orders that can be followed throughout the continuum of care. The Physician Orders for Life-Sustaining Treatment (POLST) program is the nationally recognized model for this stage of planning.
Nurse evaluation and education on how to improve safety at home for community dwelling older adults (examples of education and evaluation includes fall risks, fire and carbon monoxide (CO) detectors, transferring safety (e.g. in and out of the tub, bed, etc.) and others.
Eskenazi Health
Indianapolis, Indiana, United States
IU Health Methodist Hospital
Indianapolis, Indiana, United States
IU Health University Hospital
Indianapolis, Indiana, United States
Discordance between treatment preferences and treatment received 12 months after POST Facilitation
Chart review and comparative statistics will be used to determine discordance between patient/family preferences and care received at the end of life.
Time frame: Assessed 12 months from the date that the patient receives POST facilitation or home safety evaluation
Proportion of patients who have a completed POST form 3 months after receiving POST Facilitation
Chart review and comparative statistics will be used to determine any correlations between intervention and completion of a POST form
Time frame: Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation
Decision conflict
Decisional Conflict Scale (DCS) The DCS is used to assess decision conflict Scores range from 0 (no decisional conflict) to 100 (high decisional conflict) 0= 'strongly agree'; 1= 'agree'; 2= 'neither agree nor disagree'; 3= 'disagree'; 4= 'strongly disagree'. TOTAL SCORE 16 items are: a) summed; b) divided by 16; and c) multiplied by 25 Other papers may present scores ranging from 1 \[low decisional conflict\] to 5 \[high decisional conflict\].
Time frame: Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation
Decision quality- ACP engagement
Advance Care Planning (ACP) engagement survey
Time frame: Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation
Decision quality- POLST Knowledge
POLST Knowledge Survey
Time frame: Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation
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Effect of the intervention on cost and end of life care (EOL) for patients who die within 12 months of the intervention
Will use comparative statistics to determine any correlations between intervention and EOL care (life sustaining treatments received and hospice enrollment within 30 days of death)
Time frame: Assessed by chart review 12 months from the date that the participant receives POST facilitation or a home safety evaluation
Effect of the intervention on psychological well-being (anxiety)
Generalized Anxiety Disorder- 7 (GAD-7) (7 item inventory of anxiety)- assesses subject's self-reported anxiety for the last two weeks. Scores range from 0-21 0= 'Not at all'; 1= 'Several Days'; 2= 'More than half the days'; 3= 'Nearly every day' Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. When used as a screening tool, further evaluation is recommended when the score is 10 or greater. Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD.
Time frame: Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation
Effect of the intervention on psychological well-being (depression)
Patient Health Questionnaire-8 (PHQ-8: item inventory of depression) Scores range from 0-24 \*note that this scale is adapted from the PHQ-9, to remove the question about suicidal ideation. 0= 'Not at all'; 1= 'Several Days'; 2= 'More than half the days'; 3= 'Nearly every day' Higher scores indicate higher severity of depressive symptoms.
Time frame: Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation
Effect of the intervention on psychological well-being (post traumatic stress)
(IES-R (Impact of Events Scale- Revised- inventory for PTSD) Scores range from 0-88 0= 'Not at all'; 1= 'A little bit'; 2= 'Moderately'; 3= 'Quite a bit'; 4= 'Extremely' The Impact of Event Scale-Revised (Weiss \& Marmar, 1997) is a 22-item scale which is rated on a 0 (not at all) to 4 (extremely) scale with respect to how distressing each item has been during the past week. Scale scores are formed for the three subscales, which reflect intrusion (8 items), avoidance (8 items), and hyperarousal (6 items).
Time frame: Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation