Susan E. Hickman

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https://hdl.handle.net/1805/7275

Professor Susan Hickman (Professor, School of Nursing, Community & Health Systems) is committed to optimizing the quality of life for older adults in life’s final chapter through informed, values-based decision-making and effective communication about their treatment preferences. A primary focus of her research is the Physician Orders for Life-Sustaining Treatment (POLST) program, which improves the continuity of care by communicating patients’ treatment preferences as actionable medical orders. Findings from her research have been widely disseminated and are used across the country to support programs based on the POLST model.

Hickman co-founded the Indiana Patient Preferences Coalition, a group of individuals and organizational representatives from law, medicine, nursing, senior care, and ethics. The coalition created the Indiana POST (Physician Orders for Scope of Treatment), which is based on the national POLST model. Dr. Hickman provides education and facilitation skills-training for POST to health care providers around the state. The National Institutes of Health recently awarded her a second grant to study the quality of POLST decisions. She also serves as the Palliative Care Core lead on a Centers for Medicare and Medicaid Services innovations grant where POLST is used to reduce avoidable hospitalizations and improve care in 19 Indianapolis area nursing facilities. Her collaboration with colleagues at IU Health resulted in the launch of the Encompass Initiative, which will provide education to improve primary palliative care throughout the academic health system.

Professor Hickman’s work to improve the quality of life for older adults in life’s final chapter is another example of how IUPUI faculty are TRANSLATING RESEARCH INTO PRACTICE.

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“The RESPECT (Research in Palliative and End-of-Life Communication and Training) Center”
(Office of the Vice Chancellor for Research, 2011-04-08) Hickman, Susan E.; Sachs, Greg A.; Haase, Joan E.; Stickler, Molly Donovan
Communication is crucial to decision-making and high-quality care for patients with serious illness, but there are significant gaps in communication among patients, families, and clinicians. The Research in Palliative and End-of-Life Communication and Training (RESPECT) Center was funded in July 2010 under the IUPUI Signature Center Initiative to advance the science of palliative and end-of-life communication. The mission of the RESPECT Center is to build a collaborative, interdisciplinary scientific community of researchers and clinicians to work together to advance the science of communication in palliative and end-of-life care across the lifespan. The Center capitalizes on the complementary and expanding expertise at IU to support the advancement of research on communication in populations with serious illness that is lifethreatening, debilitating, or terminal. The Center is working to achieve its mission through three primary activities. First, the Center convenes researchers with shared expertise to utilize the collective wisdom of the interdisciplinary group in grant development and submission. The RESPECT Center uses a peer review meeting model to provide a forum for students, trainees, and faculty to develop and refine their grant writing activities focused on palliative and end-of-life care from idea development to grant revision. Second, research development is augmented by funding opportunities for peerreviewed pilot studies. Pilot funding is designed to attract new researchers to this area of study and to facilitate the generation of pilot data for more experienced researchers who are carving a new path in the field. Finally, several outreach activities are being undertaken with the goal of fostering new partnerships for translational science. The RESPECT Visiting Scholar series brings in external experts to present as part of a conference series and to meet with research faculty, clinicians, and administration to discuss issues related to advancing palliative and endof-life care research at IU. Additionally, a city-wide conference will be convened in year 3 to bring together members of the health care professional community with an interest in evidencebased practice in palliative and end-of-life care. The long-term goal of the RESPECT Center is to secure funding to permit the continued operation and expansion of Center activities.
Practical Strategies and Advice for Managing Ethical Concerns in End-of-Life Research
(Office of the Vice Chancellor for Research, 2011-04-08) Hickman, Susan; Cartwright, Juliana; Nelson, Christine; Knafl, Kathryn; Bankowski, Susan
Problem/Issue Statement A growing national interest in improving end-of-life care has increased the amount of research involving dying patients and their families. However, questions about how to best balance the pressing need for research with protecting participants trouble both investigators and institutional review boards (IRBs). Furthermore, ethical concerns were identified as a potential barrier to advancing end-of-life science at the 2004 NIH State of the Science Consensus Conference. This NIH-funded study describes ethical concerns and practical strategies for managing ethical challenges in the conduct of end-of-life research. Description of Research Methods: A qualitative, exploratory case study design followed the development of end-of-life research from proposal generation through the review process. Inclusion criteria mirrored those used in the NIH State of the Science Report. Cases were identified through a search of active studies in the NIH RePORT database and an internet search of active research funded by private foundations and institutions. Data were collected from a purposive sample of 34 principal investigators who participated by phone in semistructured interviews and provided document data regarding their experiences with the grant and IRB review processes. Interviews were recorded and transcribed with identifying information removed to protect confidentiality. Relevant document data were extracted and de-identified. Data were analyzed using exploratory qualitative case study methods. Results: The most common ethical concerns about research with end-of-life populations were recruitment strategies, the burden of study procedures, and population vulnerability. Strategies to address these concerns included gathering data about the benefits of research participation, consulting with the IRB and with more experienced researchers, using non-threatening language in the consent and other materials, being flexible in data collection protocols to accommodate participant limitations, creating back-up plans in the event of crisis, partnering with clinicians to ensure prompt attention to symptom reports, and addressing the training and emotional needs of research staff . PIs advise IRBs to seek out expert consultants for end-of-life studies, work collaboratively with investigators, simplify the consent process, and be open to the benefits of research participation for dying patients and their families rather than assuming harm will occur. Conclusion: Investigators use a variety of strategies to manage ethical issues in the conduct of end-oflife research. They advise IRBs to seek out expertise, enhance knowledge of the population, and work collaboratively with investigators. Future research will focus on gathering systematic data regarding the experiences of dying patients and their families with end-of-life research.
Hospice use among nursing home and non-nursing home patients
(Springer, 2015-02) Unroe, Kathleen T.; Sachs, Greg A.; Dennis, M.E.; Hickman, Susan E.; Stump, Timothy E.; Tu, Wanzhu; Callahan, Christopher; Department of Medicine, IU School of Medicine
BACKGROUND: For nursing home patients, hospice use and associated costs have grown dramatically. A better understanding of hospice in all care settings, especially how patients move across settings, is needed to inform debates about appropriateness of use and potential policy reform. OBJECTIVE: Our aim was to describe characteristics and utilization of hospice among nursing home and non-nursing home patients. DESIGN AND PARTICIPANTS: Medicare, Medicaid and Minimum Data Set data, 1999-2008, were merged for 3,771 hospice patients aged 65 years and above from a safety net health system. Patients were classified into four groups who received hospice: 1) only in nursing homes; 2) outside of nursing homes; 3) crossover patients utilizing hospice in both settings; and 4) "near-transition" patients who received hospice within 30 days of a nursing home stay. MAIN MEASURES: Differences in demographics, hospice diagnoses and length of stay, utilization and costs are presented with descriptive statistics. KEY RESULTS: Nursing home hospice patients were older, and more likely to be women and to have dementia (p < 0.0001). Nearly one-third (32.3 %) of crossover patients had hospice stays > 6 months, compared with the other groups (16 % of nursing home hospice only, 10.7 % of non-nursing home hospice and 7.6 % of those with near transitions) (p < 0.0001). Overall, 27.7 % of patients had a hospice stay <1 week, but there were marked differences between groups-48 % of near-transition patients vs. 7.4 % of crossover patients had these short hospice stays (p < 0.0001). Crossover and near-transition hospice patients had higher costs to Medicare compared to other groups (p < 0.05). CONCLUSIONS: Dichotomizing hospice users only into nursing home vs. non-nursing home patients is difficult, due to transitions across settings. Hospice patients with transitions accrue higher costs. The impact of changes to the hospice benefit on patients who live or move through nursing homes near the end of life should be carefully considered.
Research in Palliative and End-of-Life Communication and Training (RESPECT) Center: Year 2
(Office of the Vice Chancellor for Research, 2012-04-13) Hickman, Susan E.; Haase, Joan E.; Sachs, Greg
The mission of the Research in Palliative and End-of-Life Communication and Training (RESPECT) Center is to build a collaborative, interdisciplinary scientific community of researchers and clinicians to work together to advance the science of communication in palliative and end-of-life care across the lifespan. Center Goals: • Accelerate the development of innovative descriptive and intervention research trials relevant to communication and decision-making in children, adolescents, adults, and elders with serious and/or life-threatening illness • Develop new community partnerships for translational science to enhance palliative and end-of-life care research and practice • Create mentorship opportunities for developing scholars who will become the next generation of productive, passionate palliative and end-of-life care researchers The RESPECT Center is comprised of 18 faculty, 3 post-doctorial trainees and 3 staff members. The RESPECT Center meets twice monthly to review and discuss members’ projects, content, design, draft proposals, and brainstorming sessions. In the first year, 9 grants were submitted, 12 publications were accepted and $6,534,611 dollars awarded. In Year 1, the RESPECT center sponsored 2 visiting scholars. Finally, the RESPECT Center is funding 4 pilot projects and will continue to mentor developing scholars.
Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature
(Wiley, 2015-02) Hickman, Susan E.; Keevern, Elisabeth; Hammes, Bernard J.; IU School of Nursing
The Physician Orders for Life-Sustaining Treatment (POLST) form is a palliative care tool that contains standardized, actionable medical orders. It is designed to ensure that patient treatment preferences are elicited, communicated, and honored throughout the healthcare system. A systematic review of the literature was conducted to evaluate what is currently known about the POLST program and identify directions for future research. Twenty-three research studies focused on POLST use in the clinical setting were identified. A majority of studies have been conducted all or in part in Oregon, with chart review the most frequently used methodology. Research suggests that POLST is most commonly used in older, white patients who are near the end of life. A nonphysician facilitator usually prepares the POLST form for the physician to review and sign. The orders documented on POLST reflect a wide degree of individualization, with only approximately one-third of patients having orders reflecting the lowest level of treatment in all POLST form sections. Clinicians have generally positive attitudes regarding use of POLST yet report a wide range of challenges. POLST alters treatment in a way that is consistent with orders. However, evidence that POLST reflects patient or surrogate treatment preferences is lacking. Research is needed to evaluate the quality of POLST decisions, explore the experiences of patients and their surrogates, develop decision-support tools, improve clinician education, and assess the effect of POLST on care outcomes through intervention and population-based studies.
Advance directives in home health and hospice agencies: United States, 2007
(2011-11) Resnick, Helaine E.; Hickman, Susan E.; Foster, Gregory L.
This report provides nationally representative data on policies, storage, and implementation of advance directives (ADs) in home health and hospice (HHH) agencies in the United States using the National Home and Hospice Care Survey. Federally mandated ADs policies were followed in >93% of all agencies. Nearly all agencies stored ADs in a file at the agency, but only half stored them at the patient's residence. Nearly all agencies informed staff about the AD, but only 77% and 72% of home health agencies informed the attending physician and next-of-kin, respectively. Home health and hospice agencies are nearly universally compliant with ADs policies that are required in order to receive Medicare and Medicaid payments, but have much lower rates of adoption of ADs policies beyond federally mandated minimums.
Team-based learning and ethics education in Nursing
(2013-12) Hickman, Susan E.; Wocial, Lucia D.
This report describes the use of team-based learning concepts in an undergraduate nursing applied ethics course using established reporting guidelines. Team-based learning relies on actively engaging students in the learning process through small-group activities that facilitate the development of skills, including concept analysis, critical thinking, and problem solving. Students are divided into teams of five to seven members who collaborate throughout the semester to work through activities that build on ethics concepts introduced through reading and lectures. Nurse educators are challenged to develop educational approaches that will engage students and help them to apply what they learn from the study of ethics to the lived experience of clinical practice. The ultimate goal is to help students to develop into morally sensitive and competent professionals. Team-based learning represents a novel way to teach these skills to undergraduate nursing students.
Physician Orders for Life Sustaining Treatment for Nursing Home Residents with Dementia
(Wiley, 2015) Kim, Hyejin; Ersek, Mary; Bradway, Christine; Hickman, Susan E.; Department of Nursing, IU School of Nursing
Purpose Many nursing home (NH) residents with dementia receive burdensome, aggressive treatments at the end of life (EOL). The Physician Orders for Life-Sustaining Treatments (POLSTs) paradigm is a strategy to enhance EOL care. This article describes the history and features of the POLST paradigm, discusses the potential advantages of using this paradigm for NH residents with dementia, and briefly explores challenges that nurse practitioners (NPs) face in using the POLST for persons with dementia. Data sources Review of the literature. Conclusions Potential advantages associated with implementation of POLST in NH residents with dementia include increased communication and documentation about residents’ EOL care preferences, increased concordance between care preferences documented in POLST forms and EOL care provided to residents, and lower rates of unwanted, burdensome treatments at EOL. POLST may also guide NPs in communicating EOL care options with residents and/or their surrogates. However, difficulty interpreting and explaining POLST care options, lack of understanding of POLST, limited discussions, and issues with surrogate authority and scope of practice are challenges that NPs may face in caring for NH residents with dementia. Implications for practice NPs should assess and optimize their knowledge and skills to conduct goals of care discussions, including POLST discussions.
Research in Palliative and End-of-Life Communication and Training (RESPECT) Center: Year 3 2012-2013
(Office of the Vice Chancellor for Research, 2013-04-05) Hickman, Susan E.; Haase, Joan E.; Sachs, Greg
The mission of the Research in Palliative and End-of-Life Communication and Training (RESPECT) Center is to build a collaborative, interdisciplinary scientific community of researchers and clinicians to work together to advance the science of communication in palliative and end-of-life care across the lifespan. Center Goals: • Accelerate the development of innovative descriptive and intervention research trials relevant to communication and decision-making in children, adolescents, adults, and elders with serious and/or life-threatening illness • Develop new community partnerships for translational science to enhance palliative and end-of-life care research and practice • Create mentorship opportunities for developing scholars who will become the next generation of productive, passionate palliative and end-of-life care researchers The RESPECT Center is comprised of 19 faculty, 3 post-doctoral trainees and 3 staff members. Faculty meet twice a month to review and provide feedback to support the development of ideas and submission of research grants. In the 2011-2012 funding year, RESPECT Center faculty submitted 11 grants and received over $7.9 million dollars in funding, representing an increase of 21 % from the previous year. Additionally, faculty collaborated on the dissemination of findings and published XX articles on palliative and end-of-life care. The Center’s Visiting Scholar Series has hosted visits by 7 nationally recognized experts to consult with faculty and share their expertise with the community. On March 1, 2013, the RESPECT Center hosted a one-day statewide conference to bring together researchers and clinicians in Carmel, Indiana. The conference entitled, Translating Research into Best Practice: Improving Palliative and End-of-life Care, was attended by approximately 150 participants from 45 organizations. Finally, the RESPECT Center awarded 5 pilot study grants to help researchers develop critically important pilot data and continues to mentor developing scholars interested in the science of communication in palliative and end-of-life care.
A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Life-Sustaining Treatment (POLST) Program
(2010) Hickman, Susan E.; Nelson, Christine A.; Perrin, Nancy A.; Moss, Alvin H.; Hammes, Bernard J.; Tolle, Susan W.
Background Traditional methods to communicate life-sustaining treatment preferences are largely ineffective. The Physician Orders for Life-Sustaining Treatment (POLST) Program offers an alternative approach, but comparative data are lacking. Objectives To evaluate the relationship between communication methods (POLST versus traditional practices) and documentation of life-sustaining treatment orders, symptom assessment and management, and use of life-sustaining treatments. Design Retrospective observational cohort study conducted between June 2006 and April 2007. Setting A stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia. Subjects 1711 living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Measurements Life-sustaining treatment orders; pain, shortness of breath, and related treatments over a 7-day period; and use of life-sustaining treatments over a 60-day period. Results POLST users were more likely to have orders about life-sustaining treatment preferences beyond CPR than non-POLST users (98.0% vs. 16.1%, P<.001). There were no differences between POLST users and non-users in symptom assessment or management. POLST users with orders for Comfort Measures Only were less likely to receive medical interventions (e.g., hospitalization) than residents with POLST Full Treatment orders (P=.004), residents with Traditional DNR orders (P<.001), or residents with Traditional Full Code orders (P<.001). Conclusion POLST users were more likely to have treatment preferences documented as medical orders than non-POLST users but there were no differences in symptom management or assessment. POLST orders restricting medical interventions were associated with the lower use of life-sustaining treatments. Findings suggest the POLST program offers significant advantages over traditional methods to communicate preferences about life-sustaining treatments.

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