Disparities between preferences and practice for end-of-life care.

The study by Dr Biola et al is one of those good-news-badnews pieces that certainly points out some areas for growth and improvement, while on a positive note demonstrating that both skilled nursing facilities and assisted living facilities are doing a decent job of at least discussing residents’ preferences with respect to end-of-life care and life-sustaining treatment (LST). Although this study is of limited scope with about 300 residents from a small sample of facilities in 4 states, there are lessons to be learned from its results. Perhaps most importantly, this work highlights the need for improved processes to ensure that we do indeed provide care that is in keeping with our patients’ wishes. We should also be cautious when we use the words ‘‘life-sustaining treatment’’ because they imply to our patients that they actually do sustain life, when in fact we know that in our population, ‘‘successful’’ cardiopulmonary resuscitation (CPR) is a rarity—in spite of the fact that it works almost every time we see it done on television! So it’s good to start from that discussion point with our patients and their families. (Even the term ‘‘CPR’’ explicitly contains a reference to ‘‘resuscitation,’’ so it is no wonder that people think they will survive it, even without the TV shows)! The good news is that we seem to be discussing and eliciting treatment preferences with our long-term care patients in most cases. This is not unexpected for residents of skilled facilities, where some discussion and documentation of code status, and so forth, in the form of a Preferred Intensity of Care (PIC) or Preferred Intensity of Treatment (PIT), or more recently a Physician Orders for Life-Sustaining Treatment (POLST), or its kin such as MOLST (Medical Order for Life-Sustaining Treatment), MOST (Medical Orders for Scope of Treatment) or POST (Physician Orders for Scope of Treatment) is part of the admission process for every resident. The finding that a large majority of assisted living residents had also discussed and clarified their preferences as to at least some aspects of advance care planning (most notably DNR [Do Not Resuscitate] status) is a bit more of a surprise, but a welcome one. Most residents of both assisted and skilled facilities did not want to be resuscitated with CPR. Preferences as to enteral feeding were also known for most residents of both types of facilities, again with most subjects in this study also not wishing tube feeding. When antibiotic use