Physician Orders for Life-Sustaining Treatment Differ by Race and Ethnicity in California Nursing Homes

Racial and ethnic differences in the contents and execution of Physician Orders for Life-Sustaining Treatment (POLST) forms increased among California nursing home residents over time, according to a study published in the Journal of the American Geriatrics Society. 

The researchers examined POLST as an indicator of end-of-life care decision-making trends between clinicians, patients, and their families. 

“Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust,” researchers said. 

Nursing home residents in California were a suitable population for inclusion in this study due to state requirements for documenting POLST completion and content, according to the researchers. POLST data from more than 1 million residents from 2011 to 2016 was collected (n = 1,120,376). 

Changes in completion rate and differences by race and ethnicity in POLST content were compared after researchers adjusted for resident characteristics. Researchers noted if each POLST included cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, and DNR with selective treatment or comfort orders, as well as if the POLST was unsigned.

Researchers found the completion rate of POLSTs increased from 2011 to 2016 across all racial and ethnic groups. By 2016, at least two-thirds of nursing home residents had POLSTs. 

In 2011, Black residents were the most likely to have POLSTs with a CPR order (30.4%), followed by Hispanic residents (25.6%), then White residents (19.7%). By 2016, the use of POLSTs with a CPR order had increased to 42.5% and 38.2% for Black and Hispanic residents, respectively. White residents (28.1%) experienced the smallest increase (P < .001). 

From 2011 to 2016, increases in POLSTs containing CPR and full treatments were greater for Black and Hispanic residents than White. Meanwhile, White residents saw greater increases than Black residents in POLSTs containing DNR and DNR with selective treatment and comfort orders (P < .001). 

Additionally, there was a decrease across all racial and ethnic groups in the rate of unsigned POLSTs with CPR and DNR orders. 

“Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective,” researchers concluded. “Studies of newer POLST data are imperative.”

Reference: 
Zingmond DS, Powell D, Jennings LA, et al. Changes over time in POLST use and content by race and ethnicity among California nursing home residents. J Am Geriatr Soc. Published online April 24, 2023. doi:10.1111/jgs.18374