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| ID | Type | Description | Link |
|---|---|---|---|
| R01AG056618 | U.S. NIH Grant/Contract | View source |
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| Name | Class |
|---|---|
| National Institute on Aging (NIA) | NIH |
| National Institutes of Health (NIH) | NIH |
| Regenstrief Institute, Inc. | OTHER |
| Indiana University Health |
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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:
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).
To test the effect of POLST Facilitation on intermediate outcomes including:
To test the effect of a POLST Facilitation on secondary outcomes of cost and end-of-life care including:
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Attention Control (Home Safety Evaluation) | Other | A nurse will complete a home visit with the patient and their surrogate decision maker or other family member (if they've designated one), in which he or she will provide suggestions on how to improve the safety of the patient's home. |
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| Intervention (POST Facilitation) | Experimental | A nurse will complete a home visit with the patient and their surrogate decision maker or other family (if they've designated one), in which he or she will provide education about the POST form. The POST facilitators will be nurses trained using the Respecting Choices Advanced Steps model. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| POST Facilitation | Behavioral | 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. |
| Measure | Description | Time Frame |
|---|---|---|
| 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. | Assessed 12 months from the date that the patient receives POST facilitation or home safety evaluation |
| Measure | Description | Time Frame |
|---|---|---|
| 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 | Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation |
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Inclusion Criteria:
Patients:
65 or older
have decision making capacity OR a qualified surrogate decision maker
must meet one of the following index scores:
must be able to pass consent verification
must not be enrolled in hospice
must not have an acute illness
must give patient's provider opportunity to review the "surprise question" (e.g. would you be surprised if the patient died in the next year) to confirm anticipated mortality within the next year (14 days to respond)
must not have a POST form on file.
Exclusion criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Alexia M Torke, MD, MS | Regenstrief Institute, Indiana University | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Eskenazi Health | Indianapolis | Indiana | 46202 | United States | ||
| IU Health Methodist Hospital |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 40413042 | Derived | Torke AM, Hickman S, Wocial L, Monahan PO, Burke ES, Slaven J, Ziemba K, Montgomery C, Koch S, Cavanaugh M, Fox Ludden E. Planning Ahead: protocol for a randomised trial of advance care planning for community dwelling older adults at increased mortality risk. BMJ Open. 2025 May 24;15(5):e102186. doi: 10.1136/bmjopen-2025-102186. |
| Label | URL |
|---|---|
| POLST Facilitation in Complex Care Management: A Feasibility Study | View source |
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We will construct a de-identified data set that could be available to other researchers. Survey data, technical appendix and statistical code will be preserved and shared via the NIH-supported National Archive of Computerized Data on Aging's (NACDA) Open Aging Repository (OAR).
One year after publication of all prespecified study outcomes.
The PI will review requests based on a brief description of the request, provided by the requestor.
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| ID | Term |
|---|---|
| D001008 | Anxiety Disorders |
| D003863 | Depression |
| D013313 | Stress Disorders, Post-Traumatic |
| D010549 | Personal Satisfaction |
| ID | Term |
|---|---|
| D001523 | Mental Disorders |
| D001526 | Behavioral Symptoms |
| D001519 | Behavior |
| D040921 | Stress Disorders, Traumatic |
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| OTHER |
| Eskenazi Health | OTHER |
| Respecting Choices | UNKNOWN |
Arm 1- Attention Control group Arm 2- Intervention group
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| Home Safety Evaluation | Behavioral | 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. |
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| 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]. |
| 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 | Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation |
| Decision quality- POLST Knowledge | POLST Knowledge Survey | Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation |
| 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) | 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. | 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. | 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). | Assessed 3 months from the date that the participant receives POST facilitation or a home safety evaluation |
| Indianapolis |
| Indiana |
| 46202 |
| United States |
| IU Health University Hospital | Indianapolis | Indiana | 46202 | United States |
| D000068099 |
| Trauma and Stressor Related Disorders |