State POLST Program Maturity Status and Dying in the Nursing Home or Hospice in the United States: An Event Time Study.

OBJECTIVES

State Physician Orders for Life-Sustaining Treatment (POLST) programs ensure orders for treatment are documented for the provision of goal-concordant care at the end of life. The national POLST organization tracks the maturity stages of state programs and categorizes them as developed (beginning of use) and endorsed (benchmarks and standardized use). Examining the association between POLST program maturation and the likelihood of dying in place can help clarify how implementation stage may affect end-of-life care and place of death. This study examined the association between the state POLST program maturity stage with place of death of nursing home (NH) residents (eg, nursing home or hospice).

DESIGN

An event time study.

SETTING AND

PARTICIPANTS

This study included a 10% random sample of NH residents aged 65 and older who died between 2012 and 2018 in the United States.

METHODS

Data for NH residents were merged with data on each state's POLST development and endorsement year. Place and date of death were identified using the Minimum Data Set 3.0 and National Vital Statistics. A linear probability model assessed the likelihood of dying in a NH or hospice vs elsewhere before and after POLST implementation.

RESULTS

Among 225,149 NH residents, 74.3% had Alzheimer's disease or dementia, 67% were women, and 82.2% were White. Following POLST program development, the probability of dying in a NH or hospice increased by 1.6 percentage points (pp) in the first year (95% CI, 0.006-0.027; P = .003) and by 5.6 pp after 5 years (95% CI, 0.041-0.070). A sustained increase in likelihood of dying in place was also observed after POLST endorsement.

CONCLUSIONS AND IMPLICATIONS: POLST program maturity is associated with a higher likelihood of NH residents dying in place or in hospice, potentially supporting goal-concordant care and reducing burdensome hospital transfers near the end of life.