Geriatrics/original research
The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department

https://doi.org/10.1016/j.annemergmed.2019.05.008Get rights and content

Study objective

Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED).

Methods

This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment.

Results

A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61).

Conclusion

Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients’ preferences.

Introduction

The Physician Orders for Life-Sustaining Treatment (POLST) program was developed in the 1990s in Oregon to help prevent the provision of unwanted medical interventions to patients with advanced illness or frailty who are approaching the end of life.1 The POLST paradigm, which includes Medical Orders for Life-Sustaining Treatment and Medical Orders for Scope of Treatment forms, expanded widely during the last 2 decades, with the majority of states now having a program under some stage of development.2 Like advance directives, POLST forms allow patients to document their preferences in regard to intensity of treatment and forms of life support that they would otherwise receive by default. However, POLST goes farther than advance directives in instantiating these treatment preferences into medical orders designed to be portable across care settings.3, 4

Editor’s Capsule Summary

What is already known on this topic

Physician Orders for Life-Sustaining Treatment (POLST) forms have been recommended as a means to reducing unwanted care for patients with advanced illness.

What question this study addressed

How does the completion of POLST forms influence emergency department (ED) treatment?

What this study adds to our knowledge

In a sample of 26,128 adult patient, of whom 1,769 had completed POLST forms, individuals with POLST forms indicating limited treatment had lower ICU admission rates and shorter hospital lengths of stay than patients with POLST forms indicating full treatment. Rates of hospital admission and aggressive ED treatment did not differ according to POLST treatment preferences or POLST form completion.

How this is relevant to clinical practice

Although POLST forms may influence some aspects of ED and post-ED care, there is a need to ensure that emergency physicians are aware of their content in real time.

Observational studies have suggested that patients who complete POLST forms with treatment limitations are less likely to die in the hospital or receive high-intensity treatments compared with those who do not.4, 5, 6, 7, 8, 9 In accordance with these data, POLST has been identified by the National Quality Forum as a preferred palliative care practice,10 and the National Academy of Medicine has recommended that states “develop and implement a [POLST] paradigm program in accordance with nationally standardized core requirements.”11 However, to our knowledge randomized controlled trials of POLST do not exist, and a systematic review did not find clear evidence that POLST form completion leads to improved patient outcomes.12

The influence of POLST on the care of patients presenting to the emergency department (ED) is particularly important to elucidate, given studies suggesting that both patients and ED clinicians may misinterpret POLST forms.13, 14 Moreover, to our knowledge no study to date has compared outcomes such as receipt of aggressive medical treatment between similar patients with and without POLST forms. Therefore, we designed this study to begin to understand how POLST form completion, and the preferences stated as orders on POLST forms, might influence the aggressiveness of treatment provided to patients presenting to the ED. We hypothesized that the majority of patients with completed POLST forms who present to the ED would have orders for treatment limitations, and that treatment limitations on POLST forms at ED presentation would be associated with less aggressive medical treatment compared to similar patients without such treatment limitations on their forms.

Section snippets

Setting

The evaluation of POLST forms’ influence on the treatment of ED patients requires a study setting in which POLST are well penetrated and accessible in a measurable way. The ED at Oregon Health & Science University offers a unique opportunity to examine such questions because of Oregon’s history as the birthplace of POLST. In 2009, Oregon created a statewide POLST Registry, an electronic repository of registered POLST forms that gives providers (including emergency medical services [EMS])

Characteristics of Study Subjects

A total of 26,128 patients were included in the analyses; 1,769 patients (6.8%) had completed POLST forms (Figure). Compared with patients without POLST forms, those with them were older and with higher rates of comorbidities, including cancer, dementia, and congestive heart failure (Table 1). Among patients with POLST forms, 52.1% had full treatment orders, 33.5% had limited treatment orders, and 14.4% had comfort-measures-only orders. Thirty-two patients with POLST forms had blank medical

Limitations

To our knowledge, our study is the first to examine the association of POLST with intensity of treatment among patients presenting to the ED. The presence of Oregon’s mature POLST Registry and integration of ePOLST in the study site’s electronic health record have enabled a robust and novel description of the use of POLST among acute care patients. This study also focused on patients who came to the ED, thereby potentially reducing unmeasured differences in preferences among those with and

Discussion

This study combined data from the nation’s first and largest statewide POLST Registry15 and the electronic health record of Oregon’s only quaternary care academic medical center to yield several important findings about the use of POLST forms in the ED. First, the majority of patients with POLST forms who presented to the ED had orders for full treatment. Second, EMS and ED providers rarely accessed POLST forms before hospital admission. Perhaps for these reasons we found no difference in

References (40)

  • S.E. Hickman et al.

    National standards and state variation in Physician Orders for Life-Sustaining Treatment forms

    J Palliat Med

    (2018)
  • S.W. Tolle et al.

    Lessons from Oregon in embracing complexity in end-of-life care

    N Engl J Med

    (2017)
  • S.E. Hickman 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)
  • E.K. Fromme 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)
  • S.W. Tolle et al.

    A prospective study of the efficacy of the Physician Order Form for Life-Sustaining Treatment

    J Am Geriatr Soc

    (1998)
  • S.E. Hickman et al.

    A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the Physician Orders for Life-Sustaining Treatment program

    J Am Geriatr Soc

    (2010)
  • A.H. Moss et al.

    Physician Orders for Life-Sustaining Treatment medical intervention orders and in-hospital death rates: comparable patterns in two state registries

    J Am Geriatr Soc

    (2016)
  • D.M. Zive et al.

    Changes over time in the Oregon Physician Orders for Life-Sustaining Treatment Registry: a study of two decedent cohorts

    J Palliat Med

    (2019)
  • A National Framework and Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report

    (2006)
  • Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life

    (2015)
  • Cited by (20)

    • An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go?

      2024, Journal of the American Medical Directors Association
    • Resuscitative Decisions in the Emergency Care Setting

      2021, Journal of Emergency Nursing
      Citation Excerpt :

      In addition, it may be difficult for emergency care providers to access an AD, especially if they are not able to access the patient's electronic health record.2,3 Even when ADs are available in patients’ records, emergency care providers may fail to note their existence.4,5 Resuscitative decisions are often encountered after clinical deterioration or during end-of-life care.6

    • Oncologic Emergencies: Palliative Care in the Emergency Department Setting

      2021, Journal of Emergency Medicine
      Citation Excerpt :

      In addition, emergency medical services crews or emergency physicians may be unaware when patients present to the ED with POLST forms previously completed documenting their goals of care. A retrospective study of patients presenting to the ED with previously completed POLST forms documented in the electronic health record found that prior to admission, emergency physicians only accessed the POLST form for 6.4% of patients (19). While in certain circumstances it may be difficult to find or access previous documents detailing EOL wishes, it is crucial the physician inquire the patient or family and attempt to identify the patient's EOL wishes to provide care in accordance with the patient's goals.

    View all citing articles on Scopus

    Please see page 172 for the Editor’s Capsule Summary of this article.

    Supervising editor: Timothy F. Platts-Mills, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

    Author contributions: KCV, DZ, and DRS conceived and designed the study. KCV obtained research funding. KCV, ALL, DZ, and DRS supervised the conduct of the trial and data collection. SWT, SDH, CGS, CN, RYL, and EKK provided advice on study design and statistical analyses. KCV and ALL analyzed the data. KCV drafted the manuscript, and all authors contributed substantially to its revision. KCV takes responsibility for the paper as a whole.

    All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Ms. Zive reports receiving salary support from the Oregon POLST Registry. Dr. Vranas is supported by K12HL133115. Dr. Vranas and Ms. Lin are supported by the Collins Medical Trust. Dr. Tolle is funded by Denison Family Fund of the Oregon Community Foundation. Dr. Lee is funded by F32HL142211. Dr. Sullivan is supported by K07CA190706.

    Readers: click on the link to go directly to a survey in which you can provide feedback to Annals on this particular article.

    A podcast for this article is available at www.annemergmed.com.

    View full text