New York, New York — Nursing home residents in states that have had formal end-of-life planning programs in place the longest are significantly more likely to die in the facility or in hospice — rather than in a hospital — according to a first-of-its-kind national study published in the Journal of the American Medical Directors Association.
The research examined Physician Orders for Life-Sustaining Treatment programs — commonly called POLST or MOLST — across all 50 states, tracking how the age and maturity of those programs affected where nursing home patients spend their final days. The findings were clear: the longer a state’s program had been running, the better it performed at honoring residents’ wishes and avoiding unnecessary hospital transfers at the end of life.
By 2019, 47 states had developed some form of POLST program. But those programs vary widely — in scope, legal requirements, and how deeply they’ve been integrated into routine care. The study found that the biggest gains in outcomes didn’t come simply from having a program on the books. They came after a program had been running for years, particularly past the five-year mark.
The Difference a Decade Makes
Researchers led by Komal Patel Murali, PhD, of NYU’s Rory Meyers College of Nursing found that in states where POLST programs had reached what they called “endorsement and mature status,” the probability of a nursing home resident dying in the facility or in hospice rose steadily over time. The improvements were most dramatic in programs that had been embedded in clinical workflows long enough to actually shape how staff, physicians, and families make decisions.
“The results indicate that earlier phases of POLST program maturation — when policies, clinical workflows, and clinician uptake are actively evolving — appear to exert the strongest influence on place of death,” the research team wrote. “This pattern underscores that the impact of POLST programs on nursing home or hospice death depends not only on policy presence, but on the depth of implementation and integration into routine care.”
In other words, passing a law isn’t enough. The program has to actually take root.
A Persistent Challenge for SNFs
Skilled nursing facilities have long struggled to collect advance care planning information from incoming residents — a challenge tied to high turnover, rushed admissions, and limited time for in-depth conversations with families. Most states now require that facilities at least attempt to gather that documentation, but the quality and consistency of those efforts varies sharply from facility to facility.
The researchers pointed to staffing and operations as key factors in whether POLST programs actually make a difference at the facility level. Facilities with dedicated staff who champion the process — and those that integrate POLST conversations into regular care planning rather than waiting for a medical emergency — tend to see the best results. That tracks with broader research showing that staffing levels directly affect the quality of care residents receive, including in situations that require careful clinical judgment.
The team called for more facility-level research to understand what conditions lead to consistent POLST use — and noted that ideally, those conversations should happen before a crisis forces the decision.
What It Means for Operators
For nursing home administrators, the study reinforces something many already know intuitively: building a real culture of advance care planning takes time and deliberate effort. States with newer programs will likely see improvement as those programs mature — but facilities that wait for their state to lead the way may be behind the curve.
The research suggests that investing in POLST champions, integrating advance directive conversations into standard admission and care planning workflows, and training staff to revisit those conversations over time could meaningfully reduce unwanted hospitalizations — and help residents die where they actually want to be.
