Traditional advance directives have been advocated as 1 means to improve end-of-life care for nursing facility residents by providing documentation of treatment preferences to facilitate decision-making. However, traditional directives are problematic because they do not translate into immediate medical orders to guide specific treatment decisions based on a resident's current health status. The centerpiece of the POLSY (Physician Orders for Life-Sustaining Treatment) Program is a progressive directive document that has caught the attention of communities around the country seeking to improve end-of-life care. The POLST form has been incorporated into practice throughout the United States despite minimal data regarding the efficacy of this program. A multi-site study of the POLST Program will be conducted in order to: 1) compare the effectiveness of the POLST Program with traditional advance care planning in converting treatment preferences into orders; 2) determine the effect of advance care planning practices on symptom management; 3) compare the use of specific life-sustaining treatments for nursing facility residents with POLST forms to those with traditional advance care planning; and 4) assess whether facility use of the POLST program is associated with differences is associated with differences in end-of-life indicators from national data sets. Nursing facilities in Oregon, Wisconsin, and West Virginia will be surveyed by telephone to assess advance planning practices and use of the POLST program. Next, chart reviews will be conducted at approximately 30 nursing facilities in each state to obtain a sample of 1800 charts with and without POLST forms. Federal data will also be obtained to assess the relationship between POLST program use, Medicare, and Minimum Data Set end-of-life variables. The research proposed in this application is significant because it will provide critical data about the effectiveness of a progressive directive program in comparison to traditional advance care planning. Study findings will inform further changes to the POLST form, guide the development of educational programming, provide detailed information about end-of-life care in nursing facilities, and suggest policy change to improve care at the end of life.