Physician Orders for Life-Sustaining Treatment (POLST) forms have been implemented widely to reduce unwanted, aggressive treatment for patients with serious illness at the end of life.

“However, most studies on POLST have been limited to nursing home residents or among decedents. Very few have evaluated the influence of POLST on the care of patients who are hospitalized,” says Kelly C. Vranas, MD, assistant professor in the division of pulmonary and critical care medicine at Oregon Health & Science University.

Vranas and colleagues set out to better understand how POLST forms are used in the hospital, and whether treatment limitations on POLST influence the intensity of treatment hospital patients received.1 Some key findings:

Among patients presenting to the emergency department (ED) with POLST forms, most had orders for full treatment. “This makes us wonder whether POLST forms are actually being completed inappropriately among patients who are healthier than the intended patient population,” Vranas offers.

POLST is specifically for patients with chronic serious illness who are approaching the end of life. “There has been a push nationwide to include POLST completion as an indicator of high-quality care, particularly among primary care providers,” Vranas notes.

When used as a marker of quality, patients who are not the intended population end up completing POLST forms. These patients are too healthy for POLST and, therefore, select full code/full treatment options.

“This leads to overuse among inappropriate patients,” Vranas explains. “It has the potential to threaten patient-centered decision-making and undermine the voluntary nature of POLST completion.”

POLST forms were accessed infrequently (less than 7% of the time) by ED providers. “This is concerning,” Vranas says. The researchers could not find evidence that ED providers had accessed POLST, either by clicking on it in the electronic medical record, or by calling the Oregon POLST Registry. This suggests there is a need for standardized approaches that make it easier for ED providers to identify advance care planning documents.

“Our results highlight the need to better understand the culture and workflow of emergency providers,” Vranas adds.

Possessing a POLST form was not associated with reduced hospitalization or receipt of aggressive treatment. There are two main reasons: POLST forms are not used as originally intended, and ED providers are not accessing them anyhow. “For these reasons, any potential benefit of POLST is diluted,” Vranas observes.

Patients with treatment limitations on POLST were less likely to be admitted to the ICU. This suggests that POLST may help align treatment received with patient preferences — but only “if POLST [forms] are completed among the intended population only, and they are accessed in a timely manner,” Vranas says.

REFERENCE

  1. Vranas KC, Lin AL, Zive D, et al. The association of physician orders for life-sustaining treatment with intensity of treatment among patients presenting to the emergency department. Ann Emerg Med 2020;75:171-180.