Researchers wanted to see how the use and timing of Physician Orders for Life-Sustaining Treatment (POLST) completion has changed over time. A recent analysis compares two points in time — 2010 to 2011, and 2015 to 2016.1
“The study had several remarkable and unexpected findings,” says study co-author Susan Tolle, MD, director of the Oregon Health & Science University (OHSU) Center for Ethics in Health Care and professor of general internal medicine and geriatrics in the OHSU School of Medicine. Tolle is chair of the Oregon POLST Coalition and a leader behind the development of the POLST program.
Some key findings of the analysis include the following:
• Researchers found a 46.6% increase in POLST registry use.
“POLST-like programs are being more widely implemented across the country, and Oregon has the longest history of use and the most widespread implementation,” notes Tolle.
Of Oregonians who died between 2015 and 2016, 45% had POLST forms in the registry, compared with about 31% between 2010 and 2011. The largest increase was in patients aged 95 or older.
• There were substantial increases in time from POLST completion to death.
The length of time between form completion and death increased from an average of five weeks to 21 weeks.
• More Oregonians at end of life are indicating via POLST that they want more extensive medical care.
“While the most common order combination at the time of death remains ‘do not resuscitate and comfort measures only,’ there was a rise in orders for more aggressive life-sustaining treatments,” says Tolle.
For example, about 13% of POLST forms completed by those who died between 2015 and 2016 requested CPR, and 11% requested full medical treatment, compared with about 8% and 6%, respectively, in the earlier cohort.
“We have explored possible reasons, and in response have taken a first step by creating a policy recommendation advising against counting POLST forms as a quality measure,” says Tolle.2
• Patients with Alzheimer’s and Parkinson’s often complete POLST forms earlier in their disease than in their final year of life.
The 2019 Oregon POLST form was modified based on these and other findings. “The reasons for each of these changes may be of interest to ethics leaders in other states,” says Valerie Jimenez, BS, executive director of the Oregon POLST Coalition. These changes were made:
• The artificially administered nutrition section was removed.3
• The “P” in POLST was changed from “Physician” to “Portable” to include nurse practitioners and physician assistants.
• The form was changed from solid pink to a pink border.
“This was because of compromised quality or readability on fax or photocopy transmissions from one care setting to another,” explains Jimenez.
1. Zive DM, Jimenez VM, Fromme EK, et al. Changes over time in the Oregon physician orders for life-sustaining treatment registry: A study of two decedent cohorts. J Palliat Med 2018 Nov 21. doi: 10.1089/jpm.2018.0446. [Epub ahead of print.]
2. Tolle SW, Teno JM. Counting POLST form completion can hinder quality. Health Affairs blog, July 19, 2018.
3. Tolle SW, Jimenez VM, Eckstrom E. It’s time to remove feeding tubes from POLST forms. Journ Am Ger Soc 2019: 67(3):626-628.