Advance care planning (ACP) is a process that supports decision making about the patient?s medical care in serious illness and at the end of life. Although some older adults retain independent decision making, many require a surrogate decision maker due to Alzheimer?s Disease and Related Dementias (ADRD). High quality ACP enables decisions to be made before a crisis arises and incorporates patient values and preferences into the process. Although such planning is essential to patient-centered care, many older adults with frailty and complex medical conditions including ADRD are never offered the opportunity to engage in high quality ACP. The Physician Orders for Life Sustaining Treatment (POLST) is a state of the art ACP tool that is used to document the preferences of seriously ill patients for several types of medical treatment. Although used for thousands of seriously ill older adults, high quality counseling for POLST is a time consuming process that does not fit easily into the busy world of outpatient medicine. One solution is facilitation of POLST forms by a non-physician, followed by review and signature by a physician. The most widely used facilitator training program is Respecting Choices Last Steps. However, there are no controlled trials that have tested the impact of the Last Steps program or of other POLST implementation programs on important patient outcomes. We will conduct a randomized controlled trial to study the effect of high quality POLST Facilitation on a population of community dwelling older adults with and without ADRD who qualify for POLST based on their health status. In order to be generalizable to the clinical setting, the study will include patients making their own decisions and those who require a surrogate due to ADRD. Patients will be enrolled from primary care practices in a Midwest metropolitan area and POLST Facilitation will be delivered in the home by registered nurses trained in the Last Steps model. The primary aim is to test the effects of high quality POLST Facilitation on whether or not patients receive medical treatment concordant with preferences, compared to an attention control group. We will also measure outcomes of decision quality, cost, and care at the end of life.
If successful, this intervention to support high quality ACP and POLST will provide an evidence-based mechanism for ensuring that older adults receive the medical treatment they want and that they are able to avoid burdensome and costly care that is unlikely to benefit them. The intervention has the potential for widespread implementation through primary care practices for high risk older adults.
