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ED Physicians Remain Confused about POLST Orders for End-of-Life Care

ERIE, PA – Physician Orders for Life-Sustaining Treatment (POLST) increasingly are how seriously ill patients document their choices related to end-of-life care. The problem, according to a pair of new studies, is that emergency physicians as well as prehospital care providers demonstrate “significant confusion” when confronted with one.

The studies, published recently in the Journal of Patient Safety, find that emergency care providers vary widely in their understanding of the POLST document.

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"Our data suggest that POLST orders can be confusing for Pennsylvania emergency physicians, and likely for physicians nationwide," writes Ferdinando L. Mirarchi, DO, of University of Pittsburgh Medical Center (UPMC) Hamot in Erie, PA., and colleagues.

The POLST form is a 1-page, brightly colored document that varies in color and formatting from state to state and serves as an "active medical order" across healthcare settings. Patients use the POLST to designate their choices regarding resuscitation –either do not resuscitate (DNR) or full cardiopulmonary resuscitation (CPR) –and either full or limited treatment as well as “comfort measures" only.

The researchers surveyed Pennsylvania ED physicians and prehospital care providers, including paramedics and emergency medical technicians, to determine their understanding and interpretation of POLST forms. Survey subjects were presented with various clinical scenarios of critically ill patients as well as with POLST forms specifying different options for resuscitation and treatment.

Surveys were completed by 223 emergency physicians and 1,069 prehospital care providers, and rates of "consensus" –defined as 95% agreement –were assessed in the different situations.

Results indicate that in most of the clinical scenarios, for both emergency physicians and prehospital providers, results significantly fell short of consensus benchmarks.

“For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%–84%) and 25% to 75% chose resuscitation,” according to the results. “When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected ‘full code’ and resuscitation.”

Even in the circumstances where the POLST specified "DNR" with "comfort measures" only 10% of emergency physicians and 15% of prehospital providers indicated they would still perform CPR. Only when the POLST form specified “CPR” and “full treatment” did the situation indicate 95% agreement.

"The POLST provides medical orders that are immediately actionable and to be universally honored across various healthcare settings," note the authors, who add that the template, which generally is used by seriously ill patients facing the threat of sudden death in the year, has quickly disseminated across the United States and has now been adopted by more than 20 states with other in the process of considering it.