In general, this is a very worthwhile measure because it requires health care settings to determine if there are preexisting advance care planning documents or treatment orders completed by patients that should be respected.
1. The numerator of the measure should include a new #2 that inquires whether within 24 hours of admission the patient has been determined to lack decision-making capacity and if the advance directive, if one is present, is in effect or not. With my suggestion the present #2 would become #3 and the present #3 would become #4.
2. In the numerator in documentation #3, the measure ought to be more specific and state that "treatment orders" include a POLST Paradigm form if available. The POLST Paradigm form is especially appropriate for patients with serious illness and has been shown to have more impact on out of hospital death than advance directives. Pedraza SL, at al. J Pain Symptom Manage 2016. There are now 43 states with POLST Paradigm programs that are either endorsed or in development.
3. In the denominator, serious illness conditions for patients with kidney disease should be more general and include more than "hypertensive chronic kidney disease with stage 5 CKD or ESRD." Diabetic nephropathy is the most common cause of CKD and ESRD. Suggest a more comprehensive category for patients with CKD or ESRD: Patients 75 years or older with stage 3-5 CKD and patients with ESRD.