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Start the most difficult conversation American isn’t having- the conversation about our end of life preferences

California’s ‘Mature’ POLST Program Gains Steam

Broad acceptance of POLST in nursing homes surprises UCLA researchers


There is vast acceptance of written end of life medical orders among California’s nursing home residents, as now nearly half use the Physician Orders for Life-Sustaining Treatment (POLST) form.

A new study, published in the Jounal of General Internal Medicine, also found no difference in completion of the medical order by race or ethnicity.

Led by researchers from UCLA and funded by the California Health Care Foundation and John A. Hartford Foundation, the study is the first of a life-sustaining treatment form using the Long-Term Care Minimum Data Set (MDS). California is the only state to have added questions about POLST completion to this federally mandated clinical assessment of all residents in Medicare or Medicaid-certified nursing homes.

“Analysis of the MDS data confirms the effectiveness of grassroots outreach efforts, and will also help us focus on the facilities or communities in need of additional support to ensure best practices are being followed for POLST implementation,” said co-author Judy Thomas, CEO of the nonprofit Coalition for Compassionate Care of California, which runs the state’s POLST program.

Thomas credits increased adoption of POLST to a combination of state-level efforts that include the passage of legislation, the development of both a standardized POLST form and curriculum, and grassroots efforts by local coalitions.

“We had a two-tier approach, with a strategy at the state level and a strategy at the local level,” Thomas told Life Matters Media. “We had 25 coalitions from around the state that we worked with as well. They worked in their local communities, connecting local leaders and piloting and testing local education.”

Lead author Lee Jennings, an assistant professor of medicine in the division of geriatrics at the David Geffen School of Medicine at UCLA, said that findings regarding POLST completion were much larger than expected. “POLST is a really important part of advance care planning for nursing home residents because it is a very vulnerable population,” Jennings told LMM. “Near the end of life, they tend to have a lot of transitions – from nursing home to emergency department, to hospital to back again.”


The study found that patients with severe cognitive impairment and dementia had lower rates of POLST completion. This fact is troubling to researchers, as such patients stand to benefit more than others. “A patient with dementia is going to have trouble filling out that form on their own,” Jennings said. “Nursing homes have to contact a caregiver or proxy to complete that form. It’s another step.”

The study also revealed wide variation between facilities, with 20 percent having low POLST completion (less than 10 percent of their long-term care residents) and 40 percent having high completion (more than 80 percent of their long-term care residents).

“We want to better understand the variables,” Jennings said. “What makes some facilities really good at completing POLST with residents and others not-so good? I don’t think we know that yet.”


For millions of seriously ill Americans, advance health care directives alone will not be enough to make sure their end of life wishes are honored in case of emergency or incapacity.

POLST.001Developed by Oregon Health and Science University medicine professor Dr. Susan Tolle in the 1990s, POLST allows people to make clear what medical treatments they desire or wish to avoid – they may indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes, among other things. They also indicate the location where they prefer to receive care.

POLST, far more detailed than conventional living wills or advance directives, must be signed by a medical practitioner to be valid. Ideally, a POLST form is completed only after meaningful conversation among the patient, his or her doctor and family.

“POLST is a nice way to really articulate what a patient’s preferences are,” Jennings said. “Their wishes are clearly documented for the patient and loved ones who may have to speak on their behalf. It helps a physician who knows them well or maybe doesn’t know them well. Everybody can be on the same page in the moment.”

Jennings called POLST a “portal,” because it is designed to travel with patients across care settings.

California adopted the POLST program in 2009. It is one of three states where hospitals and nursing homes in every region use the medical order.


– Completion increased from 33 percent at the beginning of 2011 to 49 percent by the end of that year

– Long-stay nursing home residents were more likely than short-stay residents to have completed the form

– Severely cognitively impaired long-term care residents were 24 percent less likely than unimpaired residents to have completed the order

– The study shows no difference in completion among white non-Hispanic, black and Hispanic residents

– 13 percent of the forms lacked a signature, rendering the order invalid

– Disclosure: Life Matters Media Co-Founders Randi Belisomo and Dr. Mary F. Mulcahy are members of the Illinois POLST Task Force.

– Image via Pixabay