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:

  • Check with emergency medical services to see if they know the patient’s code status.
  • The electronic health record can prompt an ED clinician to confirm the patient’s code status.
  • Ask the patient what their wishes are upon arrival or before admission.
  • Call the healthcare proxy or surrogate decision-maker to confirm the patient’s wishes.
  • Communicate and document a patient’s code status when the patient is either admitted or discharged to an outside facility.
  • Require a valid POLST to be reaffirmed or completed before the patient is discharged.

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.”

REFERENCES

  1. Fromme EK, Zive D, Schmidt TA, et al. Association between Physician Orders for Life-Sustaining Treatment for scope of treatment and in-hospital death in Oregon. J Am Geriatr Soc 2014;62:1246-1251.
  2. Lee RY, Brumback LC, Sathitratanacheewin S, et al. Association of Physician Orders for Life-Sustaining Treatment with ICU admission among patients hospitalized near the end of life. JAMA 2020;323:950-960.