Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: Treatment Preferences
Collected For: PAL-04
Definition:Medical record documentation includes the patient’s preferences regarding life-sustaining treatments, or there is documentation of a discussion or attempted discussion regarding life-sustaining treatment preferences.

Documentation should include CPR preference as well as other life-sustaining treatments including, but not limited to:
  • Blood transfusion
  • Dialysis
  • Hospitalization or transfer preference
  • Intravenous [IV] fluids
  • Mechanical ventilation
  • Surrogate decision maker
  • Tube feeding
  • Use of antibiotics
Suggested Data Collection Question:Does the medical record indicate the patients’ preferences regarding or discussion of life-sustaining treatments?
Allowable Values:

1       Yes, there is documentation of the patients’ preferences regarding life-sustaining treatments.

2       Yes, there is documentation of a discussion or attempted discussion about the patients’ preferences regarding life-sustaining treatments.

3       No, there is no documentation of the patients’ preferences or discussion of preferences or unable to determine from medical record documentation.
Notes for Abstraction:
  • “Responsible party” refers to the legally responsible or authorized individual, such as the Health Care Power of Attorney or legal guardian. In cases where there is no legal guardian or power of attorney identified, the organization should use state law guidance to identify the appropriate surrogate decision-maker.
  • In order to select “1” or “2” if a party other than the patient was asked about preferences regarding life-sustaining treatments, there must be evidence in the clinical record that the responsible party as defined above was asked about preferences.
  • If there is no documentation that a discussion occurred or was attempted with the patient or responsible party, select value “3.”
  • A discussion about preference for life-sustaining treatment can be initiated by any member of the palliative care core interdisciplinary team. The core interdisciplinary team is comprised of the following: Physician(s); Registered nurse(s) or advanced practice nurse(s); Chaplain(s) or, spiritual care professional(s); Social worker(s).
  • Orders or short statements alone, such as “DNR/DNI” or “full code” without evidence of discussion or involvement from patient/responsible party, are not sufficient to select “1”. For example "discussed CPR status, patient wishes to remain full code" select value "1".
  • If there is no discussion regarding CPR preferences, select value "3".
  • There is no comprehensive list of life-sustaining treatments. Documentation in the clinical record indicating CPR preference and any life-sustaining treatments is sufficient to select “1” or “2”. Examples may include, as appropriate for the patient: ventilator support, tube feeding, dialysis, blood transfusion, antibiotics, and intravenous [IV] fluids.
  • Documentation must include the specific life-sustaining treatments discussed, for example “discussed use of tube feeding, IV fluids, ventilator, and CPR, patients does not wish to have any of these treatments” select value "1".
  • A newly completed Physician/Practitioner Orders for Life-Sustaining Treatment (POLST) form (or other state specific treatment preference form) that is signed by the organization clinician after the admission to organization is sufficient to select “1”, provided there is evidence of involvement from patient/responsible party, such as signature of the patient or responsible party on POLST forms, or clinical documentation, such as “treatment preference confirmed with responsible party.”
  • If a patient is admitted to organization with a pre-existing POLST that was signed in a prior care setting, the organization should re-affirm the patient’s preferences that appear in the pre-existing POLST. This re-affirmation of preferences should be documented in the medical record. Documentation, such as “discussed life-sustaining treatment preferences during the admission visit with patient” select “1”. If the clinical record is ambiguous as to whether the organization attempted to re-affirm patient preferences present in a pre-existing POLST, select “3.”
  • If there is documentation in the medical record that the organization attempted to have a conversation with the patient and responsible party, but both the patient and responsible party explicitly refused to discuss the topic with the organization, select value “2.” This would include statements such as, “I don’t want to talk about this” or “I’m only going to talk to my priest about this”.
  • If the organization attempted to discuss the topic, but the patient was unable to discuss because of their clinical status and the responsible party explicitly refused to discuss, select value “2.”
  • If there is documentation in the medical record that the organization brought up the topic of life-sustaining treatment, and there was a conversation with the patient and/or responsible party, but the conversation does not result in the patient stating a preference, select value “2”
Suggested Data Sources:

  • History and physical
  • Progress notes
  • Discharge summary
  • Care transition record
  • Consultation form
  • Discharge planning form
  • Palliative care consultation notes
  • Palliative care team progress notes
  • Palliative care initial encounter notes
  • Palliative care admission assessment
  • State specific treatment preference forms may include:
    • COLST (Clinician Orders for Life Sustaining Treatment)
    • MOLST (Medical Orders for Life-Sustaining Treatment)
    • MOST (Medical Orders for Scope of Treatment)
    • POLST (Physician/Practitioner Orders for Life-Sustaining Treatment)
    • POST (Physician Orders for Scope of Treatment)
    • TPOPP (Transportable Physician Orders for Patient Preferences)
Additional Notes: Notes adapted from: Guidance Manual for Completion of the Hospice Item Set (HIS), Centers for Medicare and Medicaid Services, Hospice Quality Reporting Program, V 1.02 Effective June 28, 2015
Guidelines for Abstraction:
Inclusion Exclusion
None None

Treatment Preferences
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)