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How well do POLST forms assure that patients get the end-of-life care they requested?
EVIDENCE SUMMARY
The POLST form offers choices within 4 treatment areas: “attempt CPR” or “allow natural death” if the patient is in cardiopulmonary arrest; “comfort,” “limited,” or “full” medical interventions if pulse or breathing is present; choices of additional orders, including intravenous fluids, feeding tubes, and antibiotics; and additional written orders. Most POLST studies used cross-sectional and retrospective cohort designs and assessed whether CPR was attempted. Fewer studies also evaluated adherence to orders in the other treatment areas.
Community settings: Patients with POLST more likely to die out of hospital
The largest study of POLST use in community settings evaluated deaths in Oregon over one year.1 It found that patients who indicated “do not attempt CPR” on a POLST form were 6 times more likely to die a natural, out-of-hospital death than those who had no POLST form (TABLE1-10).
A West Virginia study found that patients with POLST forms had 30% higher out-of-hospital death rates than those with traditional advanced directives and no POLST.2 In a Wisconsin study, no decedents who indicated DNR on their POLST forms received CPR.3
One study that evaluated the consistency of actual medical interventions with POLST orders in all 4 treatment areas found it to be good in most areas (“feeding tubes,” “attempting CPR.” “antibiotics,” and “IV fluids”) except “additional written orders.4
Skilled nursing facilities: Generally high adherence to POLST orders
The largest study to evaluate the consistency of treatments with POLST orders among nursing home residents found high adherence overall (94%).5 Caregivers performed CPR on none of 299 residents who selected “DNR.” However, they did not administer CPR to 6 of 7 who chose “attempt CPR” and administered antibiotics to 32% of patients who specified “no antibiotics” on their POLST forms.5
A second study of nursing home residents who selected “comfort measures only” also found high consistency for attempting CPR, intensive care admission, and ventilator support, although physicians hospitalized 2% of patients to extend life.6 Similarly, treatments matched POLST orders well overall in a Washington state study, although one patient got a feeding tube against orders.7
POLST adherence is good, but can EMS workers find the form?
A study comparing emergency medical services (EMS) management with POLST orders in an Oregon registry found good consistency.8 EMS providers didn’t attempt or halted CPR in most patients with DNR orders who were found in cardiac arrest and initiated CPR in most patients who chose “attempt CPR.” EMS providers initiated CPR in the field on 11 patients (22%) with a DNR order but discontinued resuscitation en route to the hospital.
In a smaller study, EMS providers never located paper POLST forms at the scene in most cases.9
Hospice: POLST orders prevent unwanted Tx, except maybe antibiotics
A study evaluating management in hospice programs in 3 states found that care providers followed POLST orders for limited treatment in 98% of cases.10 No patients received unwanted CPR, intubation, or feeding tubes. POLST orders didn’t predict whether patients were treated with antibiotics, however.
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. Pedraza SL, Culp S, Falkenstine EC, et al. POST forms more than advance directives associated with out-of-hospital death: insights from a state registry. J Pain Symptom Manage. 2016; 51:240-246.
3. Hammes B, Rooney BL, Gundrum JD, et al. The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliative Med. 2012;15:77-85.
4. Lee MA, Brummel-Smith K, Meyer J, et al. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. J Am Geriatr Soc. 2000;48:1219-1225.
5. Hickman SE, Nelson CA, Moss AH, et al. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011;59:2091-2099.
6. Tolle SW, Tilden VP, Nelson CA, et al. A prospective study of the efficacy of the physician order form for life sustaining treatment. J Am Ger Soc.1998;46:1097-1102.
7. Meyers J, Moore C, McGrory A, et al. Physician orders for life-sustaining treatment form: honoring end-of-life directives for nursing home residents. J Geron Nursing. 2004;30:37-46.
8. Richardson DK, Fromme E, Zive D, et al. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann Emerg Med. 2014;63:375-383.
9. Schmidt T, Olszewski EA, Zive D, et al. The Oregon physician orders for life-sustaining treatment registry: a preliminary study of emergency medical services utilization. J Emerg Med. 2013;44:796-805.
10. Hickman SE, Nelson CA, Moss AH, et al. Use of the physician orders for life-sustaining treatment (POLST) paradigm program in the hospice setting. J Palliat Med. 2009;12:133-141.
EVIDENCE SUMMARY
The POLST form offers choices within 4 treatment areas: “attempt CPR” or “allow natural death” if the patient is in cardiopulmonary arrest; “comfort,” “limited,” or “full” medical interventions if pulse or breathing is present; choices of additional orders, including intravenous fluids, feeding tubes, and antibiotics; and additional written orders. Most POLST studies used cross-sectional and retrospective cohort designs and assessed whether CPR was attempted. Fewer studies also evaluated adherence to orders in the other treatment areas.
Community settings: Patients with POLST more likely to die out of hospital
The largest study of POLST use in community settings evaluated deaths in Oregon over one year.1 It found that patients who indicated “do not attempt CPR” on a POLST form were 6 times more likely to die a natural, out-of-hospital death than those who had no POLST form (TABLE1-10).
A West Virginia study found that patients with POLST forms had 30% higher out-of-hospital death rates than those with traditional advanced directives and no POLST.2 In a Wisconsin study, no decedents who indicated DNR on their POLST forms received CPR.3
One study that evaluated the consistency of actual medical interventions with POLST orders in all 4 treatment areas found it to be good in most areas (“feeding tubes,” “attempting CPR.” “antibiotics,” and “IV fluids”) except “additional written orders.4
Skilled nursing facilities: Generally high adherence to POLST orders
The largest study to evaluate the consistency of treatments with POLST orders among nursing home residents found high adherence overall (94%).5 Caregivers performed CPR on none of 299 residents who selected “DNR.” However, they did not administer CPR to 6 of 7 who chose “attempt CPR” and administered antibiotics to 32% of patients who specified “no antibiotics” on their POLST forms.5
A second study of nursing home residents who selected “comfort measures only” also found high consistency for attempting CPR, intensive care admission, and ventilator support, although physicians hospitalized 2% of patients to extend life.6 Similarly, treatments matched POLST orders well overall in a Washington state study, although one patient got a feeding tube against orders.7
POLST adherence is good, but can EMS workers find the form?
A study comparing emergency medical services (EMS) management with POLST orders in an Oregon registry found good consistency.8 EMS providers didn’t attempt or halted CPR in most patients with DNR orders who were found in cardiac arrest and initiated CPR in most patients who chose “attempt CPR.” EMS providers initiated CPR in the field on 11 patients (22%) with a DNR order but discontinued resuscitation en route to the hospital.
In a smaller study, EMS providers never located paper POLST forms at the scene in most cases.9
Hospice: POLST orders prevent unwanted Tx, except maybe antibiotics
A study evaluating management in hospice programs in 3 states found that care providers followed POLST orders for limited treatment in 98% of cases.10 No patients received unwanted CPR, intubation, or feeding tubes. POLST orders didn’t predict whether patients were treated with antibiotics, however.
EVIDENCE SUMMARY
The POLST form offers choices within 4 treatment areas: “attempt CPR” or “allow natural death” if the patient is in cardiopulmonary arrest; “comfort,” “limited,” or “full” medical interventions if pulse or breathing is present; choices of additional orders, including intravenous fluids, feeding tubes, and antibiotics; and additional written orders. Most POLST studies used cross-sectional and retrospective cohort designs and assessed whether CPR was attempted. Fewer studies also evaluated adherence to orders in the other treatment areas.
Community settings: Patients with POLST more likely to die out of hospital
The largest study of POLST use in community settings evaluated deaths in Oregon over one year.1 It found that patients who indicated “do not attempt CPR” on a POLST form were 6 times more likely to die a natural, out-of-hospital death than those who had no POLST form (TABLE1-10).
A West Virginia study found that patients with POLST forms had 30% higher out-of-hospital death rates than those with traditional advanced directives and no POLST.2 In a Wisconsin study, no decedents who indicated DNR on their POLST forms received CPR.3
One study that evaluated the consistency of actual medical interventions with POLST orders in all 4 treatment areas found it to be good in most areas (“feeding tubes,” “attempting CPR.” “antibiotics,” and “IV fluids”) except “additional written orders.4
Skilled nursing facilities: Generally high adherence to POLST orders
The largest study to evaluate the consistency of treatments with POLST orders among nursing home residents found high adherence overall (94%).5 Caregivers performed CPR on none of 299 residents who selected “DNR.” However, they did not administer CPR to 6 of 7 who chose “attempt CPR” and administered antibiotics to 32% of patients who specified “no antibiotics” on their POLST forms.5
A second study of nursing home residents who selected “comfort measures only” also found high consistency for attempting CPR, intensive care admission, and ventilator support, although physicians hospitalized 2% of patients to extend life.6 Similarly, treatments matched POLST orders well overall in a Washington state study, although one patient got a feeding tube against orders.7
POLST adherence is good, but can EMS workers find the form?
A study comparing emergency medical services (EMS) management with POLST orders in an Oregon registry found good consistency.8 EMS providers didn’t attempt or halted CPR in most patients with DNR orders who were found in cardiac arrest and initiated CPR in most patients who chose “attempt CPR.” EMS providers initiated CPR in the field on 11 patients (22%) with a DNR order but discontinued resuscitation en route to the hospital.
In a smaller study, EMS providers never located paper POLST forms at the scene in most cases.9
Hospice: POLST orders prevent unwanted Tx, except maybe antibiotics
A study evaluating management in hospice programs in 3 states found that care providers followed POLST orders for limited treatment in 98% of cases.10 No patients received unwanted CPR, intubation, or feeding tubes. POLST orders didn’t predict whether patients were treated with antibiotics, however.
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. Pedraza SL, Culp S, Falkenstine EC, et al. POST forms more than advance directives associated with out-of-hospital death: insights from a state registry. J Pain Symptom Manage. 2016; 51:240-246.
3. Hammes B, Rooney BL, Gundrum JD, et al. The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliative Med. 2012;15:77-85.
4. Lee MA, Brummel-Smith K, Meyer J, et al. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. J Am Geriatr Soc. 2000;48:1219-1225.
5. Hickman SE, Nelson CA, Moss AH, et al. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011;59:2091-2099.
6. Tolle SW, Tilden VP, Nelson CA, et al. A prospective study of the efficacy of the physician order form for life sustaining treatment. J Am Ger Soc.1998;46:1097-1102.
7. Meyers J, Moore C, McGrory A, et al. Physician orders for life-sustaining treatment form: honoring end-of-life directives for nursing home residents. J Geron Nursing. 2004;30:37-46.
8. Richardson DK, Fromme E, Zive D, et al. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann Emerg Med. 2014;63:375-383.
9. Schmidt T, Olszewski EA, Zive D, et al. The Oregon physician orders for life-sustaining treatment registry: a preliminary study of emergency medical services utilization. J Emerg Med. 2013;44:796-805.
10. Hickman SE, Nelson CA, Moss AH, et al. Use of the physician orders for life-sustaining treatment (POLST) paradigm program in the hospice setting. J Palliat Med. 2009;12:133-141.
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. Pedraza SL, Culp S, Falkenstine EC, et al. POST forms more than advance directives associated with out-of-hospital death: insights from a state registry. J Pain Symptom Manage. 2016; 51:240-246.
3. Hammes B, Rooney BL, Gundrum JD, et al. The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliative Med. 2012;15:77-85.
4. Lee MA, Brummel-Smith K, Meyer J, et al. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. J Am Geriatr Soc. 2000;48:1219-1225.
5. Hickman SE, Nelson CA, Moss AH, et al. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011;59:2091-2099.
6. Tolle SW, Tilden VP, Nelson CA, et al. A prospective study of the efficacy of the physician order form for life sustaining treatment. J Am Ger Soc.1998;46:1097-1102.
7. Meyers J, Moore C, McGrory A, et al. Physician orders for life-sustaining treatment form: honoring end-of-life directives for nursing home residents. J Geron Nursing. 2004;30:37-46.
8. Richardson DK, Fromme E, Zive D, et al. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann Emerg Med. 2014;63:375-383.
9. Schmidt T, Olszewski EA, Zive D, et al. The Oregon physician orders for life-sustaining treatment registry: a preliminary study of emergency medical services utilization. J Emerg Med. 2013;44:796-805.
10. Hickman SE, Nelson CA, Moss AH, et al. Use of the physician orders for life-sustaining treatment (POLST) paradigm program in the hospice setting. J Palliat Med. 2009;12:133-141.
Evidence-based answers from the Family Physicians Inquiries Network
EVIDENCE-BASED ANSWER:
Quite well, for cardiopulmonary resuscitation (CPR). Most patients (91%-100%) who select “do not resuscitate” (DNR) on their physician’s orders for life-sustaining treatment (POLST) forms are allowed a natural death without attempted CPR across a variety of settings (community, skilled nursing facilities, emergency medical services, and hospice). Few patients (6%) who select “comfort measures only” die in the hospital, whereas more (22%) who choose “limited interventions,” and still more (34%) without a POLST form, die in the hospital (strength of recommendation [SOR]: B, large, consistent cross-sectional and cohort studies).
Most patients (84%) who select “attempt resuscitation” receive resuscitation for out-of-hospital cardiac arrest in emergency services settings (SOR: B, small retrospective cohort study).
POLST orders declining other services (intravenous fluids, intensive care, intubation, feeding tubes) are carried out in most (84%-100%) cases. POLST orders regarding antibiotic treatments are less effectively implemented (SOR: B, moderate-sized retrospective chart review).
