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Monday, December 2, 2013

Article on Nursing Homes


Marshall B. Kapp, J.D., M.P.H. (Director, Florida State University Center for Innovative Collaboration in Medicine & Law) recently published an article entitled, The Nursing Home as Part of the Polst Paradigm, 36 Hamline L. Rev. 151 (Spring 2013).  Provided below is the introduction to his article:

Improving the quality of care and quality of life for individuals with advanced, irreversible illness is a paramount goal from the perspectives of both ethics and public health. One aspect of achieving such improvement entails assuring that the care those individuals receive is consistent with their important, authentic, personal values and wishes.  The physician and other professional members of the health care team are the experts on medical means to achieve specific outcomes, but the individual patient is the best expert about his or her own values, goals, and preferences.  The quality of care and quality of life challenge is exacerbated by the fact that, as the medical and social ramifications of advanced illness unfold over time, many people receive care within several different settings, often moving back and forth among settings as their immediate needs and resources change. Consequently, it is imperative that the mechanisms we develop for the purpose of enforcing persons' personal care values and preferences follow individuals across and throughout the care continuum.

Many people with advanced, irreversible illness reach a point at which they need to receive most of their care in a nursing home, and a large proportion of those individuals ultimately die in that venue after receiving various forms of medical care there.  The care actually provided to nursing home residents during the period prior to their deaths too frequently deviates from that which they, on the basis of their own values, really want.  This article discusses one initiative-the Physician Orders for Life-Sustaining Treatment (POLST) paradigm-that holds the promise of improving the quality of care and quality of life for nursing home residents with advanced, irreversible illness by more closely reconciling the details of the actual care they receive at the most crucial juncture of their lives with their desired care in that context.

The next section of this article provides background on the intersection of nursing homes and the care of people with advanced, irreversible illness. First, it outlines the importance of nursing homes within the contemporary American health care enterprise and then describes the ways in which medical care decisions are made today in this context and identifies some of the major shortcomings of the status quo.  The ensuing section proposes the POLST paradigm as a viable alternative to the status quo, laying a foundation by setting forth information on the nomenclature, definition, and legal status of the POLST concept and then specifically exploring the adaptability of the POLST paradigm to the nursing home setting. The advantages of this mechanism as compared with conventional Advance Directives (ADs) are highlighted. The article concludes that POLST can and should be an integral facet of ideal nursing home care for all willing and appropriate residents.


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