The trusted source for
healthcare information and
Research has demonstrated that completed Physician Orders for Life-Sustaining Treatment (POLST) forms can help people with chronic illness avoid unwanted hospitalizations and CPR.1
“However, we don’t know very much about what happens when patients with POLST forms are admitted to the hospital near the end of life,” says Robert Y. Lee, MD, MS, acting instructor of medicine in the division of pulmonary, critical care, and sleep medicine at the University of Washington.
Researchers reviewed the charts of 1,818 patients with chronic illness and POLST forms who were hospitalized within six months of death.2 Hospitalized patients who selected limited or comfort-only care were less likely to receive intensive care than those who selected full treatment.
“In other words, what patients put on their POLST forms matters,” says Lee, the study’s lead author.
Patients whose POLST forms read “avoid intensive care” are less likely to receive intensive care if hospitalized. However, the authors also found 38% of hospitalized patients with POLST orders for limited care were admitted to the intensive care unit anyway. “Although we hypothesized that this must happen with some frequency, we did not expect it to be quite so common,” Lee reports.
Care that contradicts the patient’s POLST form is not necessarily inappropriate. Unanticipated circumstances can arise, causing people to change their minds about the care they want to receive. “POLST-discordant care may still be ethically appropriate at times,” Lee offers.
However, POLST-discordant care sometimes happens due to factors that are not patient-centered, leading to ethically inappropriate care. “We are currently conducting qualitative research studies to characterize exactly how and why POLST-discordant care happens, and how often such care is potentially inappropriate,” Lee notes.
POLST forms should be honored in the emergency department (ED) unless the patient or proxy alerts clinicians that there has been a change in the patient’s wishes, says Jay M. Brenner, MD, FACEP. An ethical dilemma can develop if a patient does not present to the ED with a POLST, a patient cannot decide what his or her wishes are, and a healthcare proxy or surrogate decision-maker is unavailable. “This likelihood has been exacerbated by the COVID-19 pandemic due to strict visitor restrictions,” Brenner notes.
If there is not enough time to search for a POLST, resuscitation becomes a default approach. “No one wants to have it on their conscience that they withheld life-sustaining treatments to a patient who would have wanted them,” Brenner says.
These practices can help ensure the ED clinician can identify the patient’s wishes quickly:
When used properly, the POLST form can help clinicians honor a patient’s preferences. “It is a helpful tool to aid the clinician in determining what exactly those wishes were and are,” Brenner says. “This is a basic tenet of bioethics and humane healthcare.”
Financial Disclosure: Physician Editor Arthur R. Derse, MD, JD, Nurse Planner Susan Solverson, RN, BSN, CMSRN, Editor Jonathan Springston, Editor Jill Drachenberg, Editorial Group Manager Leslie Coplin, Accreditations Director Amy M. Johnson, MSN, RN, CPN, and Author Stacey Kusterbeck report no consultant, stockholder, speakers’ bureau, research, or other financial relationships with companies having ties to this field of study.