Exploring provider-surrogate communication during POLST discussions for individuals with advanced dementia

ABSTRACT

Objectives: This qualitative descriptive study explored provider-surrogate communication during Physician Orders for Life-Sustaining Treatment (POLST) discussions for patients with advanced dementia.

Methods: Data from participant observations and audio-recordings of ten POLST discussions were analyzed using directed content analysis within the context of an existing conceptual model of Communication and Surrogate Decision Making.

Results: Surrogates primarily focused on making sense of the clinical information about life-sustaining treatments during POLST conversations. Providers delivered clinical information about the trajectory of dementia, life-sustaining treatments, and/or features of POLST. They also demonstrated emotional support, by valuing what the surrogate said, acknowledging the surrogate's emotions, listening carefully, understanding the patient as a person, and eliciting questions. However, providers rarely conveyed comprehensive information about the patient's current condition and end-of-life treatment options. Also, open communication of expectations and preferred decision-making roles was rarely observed during the discussions.

Conclusion: Findings highlight areas that require providers’ attention to conduct effective communication, such as delivering comprehensive information about life-sustaining treatments including discussion of risks and benefits in the context of dementia. Findings also support the use of the conceptual model as a framework to examine provider-surrogate communication in the context of POLST discussions, advanced dementia, and non-hospital settings. Additional research is necessary to confirm these findings in larger, more diverse groups of patients, surrogates, and providers.

KEYWORDS:

• Surrogate decision making
• end-of-life care planning
• palliative care
• dementia
• physician orders for life-sustaining treatment

Acknowledgement

We would like to thank Drs. Pamela Cacchione and Karen Hirschman at the University of Pennsylvania School of Nursing for their comments on the manuscript. We also want to acknowledge the Advanced Qualitative Research Collective at the same institution for their support and comments throughout the implementation of this study.

Disclosure statement

The authors report no conflicts of interest

Additional information

Funding

This work was supported by the following: the National Institutes of Health and National Institute of Nursing Research under Grant number 1F31NR015702-01A1 and T32NR009356; the Sigma Theta Tau International under Grant number 566734; the John A. Hartford Foundation's National Hartford Centers of Gerontological Nursing Excellence Award Program under Grant number 13-115; and the University of Pennsylvania School of Nursing Office of Nursing Research Award.