Surrogate preferences on Physician Orders for Life-Sustaining Treatment (POLST) forms were 60% less likely to choose “all treatment” than patients who made their own decisions, found a new study.1
“We thought it was a good tool for some of our inpatients, and wanted to see how it was really being used,” says Rachelle Bernacki, MD, MS, one of the study’s authors and associate director of the Serious Illness Care Program at Ariadne Labs in Boston.
Researchers compared treatment preferences of patients to those of surrogates on the POLST forms. They reviewed 606 Massachusetts POLST forms at three hospitals and the corresponding patient electronic medical records (EMRs). Surrogates signed 253 of the forms.
The fact that such a high percentage of forms were signed by surrogates instead of patients wasn’t too surprising. The researchers expected this was the case: Hospitalized patients are often too sick to discuss and sign themselves the forms that signify agreement with the clinicians’ POLST orders. It also offers an explanation for surrogates’ tendency to limit life-sustaining care.
“It’s not uncommon, as patients get sicker, to have less aggressive care,” says Bernacki.
The timing of completion of POLST forms is the real concern, says Bernacki. The hope is that more patients will discuss and complete them with their clinicians earlier.
The hospital’s Serious Illness Care Program has been in place for five years. Clinicians are asked: “Would you be surprised if this patient died in the next year?” If the answer is no, data are collected on whether anyone on the clinical team has had a serious illness conversation with the patient. Of the patients identified in the Integrated Care Management Program at Brigham and Women’s Hospital in Boston, 73% held conversations. Hopefully, this results in completed POLST forms, ideally with surrogates present.
“Our care management nurses have done a phenomenal job of that. We’ve had very good success,” says Bernacki.
POLST form completion requires more than just asking the patient, “Do you want to be DNR [do not resuscitate] or not?” A more in-depth discussion is necessary. “Best practice is to assess the patient’s understanding of the illness,” says Bernacki.
Next, clinicians explore what the patient wants to know regarding his or her prognosis. Finally, the discussion turns to what is most important to the patient. Clinicians ask open-ended questions such as “What are you worried about?” They also ask, “How much are you willing to go through for the possibility of gaining more time?”
“This question is fairly well understood by patients,” says Bernacki. Some state they will go through anything to stay alive one more day, while others are unsure if they want to endure hospitalization again.
“We can then translate that to an order on the form,” says Bernacki.
Specific guidance makes clinicians noticeably less anxious about the tough conversations. At first, many fear it will take too much time. A previous study determined the median time was 21.8 minutes for physicians and 26 minutes for nurses.2
“It’s not a short conversation. But it’s also not so long that it’s not feasible to fit into your work day,” says Bernacki.
1. Chen EE, Pu CT, Bernacki RE, et al. Surrogate preferences on the physician orders for life-sustaining treatment form. Gerontologist. 2018 May 17. doi: 10.1093/geront/gny042. [Epub ahead of print].
2. Lakin JR, Koritsanszky LA, Cunningham R, et al. A systematic intervention to improve serious illness communication in primary care. Health Aff (Millwood). 2017 Jul 1;36:1258-1264. doi: 10.1377/hlthaff.2017.0219.