Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life

Abstract

IMPORTANCE Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations.OBJECTIVES To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. DESIGN, SETTING, AND PARTICIPANTSRetrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system.EXPOSURES POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. MAIN OUTCOMES AND MEASURESThe primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. RESULTS Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08...

Palliative Care in Advanced Dementia

“…ACP was associated with less tube feeding (85) and contributed to minimize hospital admissions (110) and increased the use of hospice structures (112). In comparison to people with other advanced diseases in hospital care people with dementia were less likely to receive intervention opposed to their treatment goal of comfort (113).…”

Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)

“…I think this "lack of validity and reliability" of said "death plans" explain findings from recent published studies of ACP. In a multicenter audit of "Physician Order for the use of Life-Sustaining Treatments (POLST)" documents published in JAMA [8], Lee and colleagues analyzed the health care trajectory of patients living with chronic illness who had a POLST and were hospitalized in the last 6 months of life. They documented the impact of POLST on end of life care that up to 38% of patients with POLST receive "discordant" care.…”

“…Over the past decade, have we made progress in "preparing patients for end of life decision-making?" Recent studies suggest there are still considerable problems with the current approach [6][7][8][9][10][11][12][13][14]16]. Health care expenditures in the last years of life are increasing at a phenomenal rate suggesting the current approach to "end of life" planning is not working [20].…”

“…It has been more than a decade since leaders in the field proposed this concept of preparing patients for future decision-making, but it was still ensconced in the context of end of life medical care [ 19 ]. Over the past decade, have we made progress in “preparing patients for end of life decision-making?” Recent studies suggest there are still considerable problems with the current approach [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 16 ]. Health care expenditures in the last years of life are increasing at a phenomenal rate suggesting the current approach to “end of life” planning is not working [ 20 ].…”

Conflicting Orders in Physician Orders forLife‐SustainingTreatment Forms

“…3,4 Treatment-limiting POLST orders are associated with less in-hospital death, hospitalization, intensive care unit admission, and unwanted cardiopulmonary resuscitation (CPR). 2,5 However, to be effective, POLSTs must be interpretable and actionable by clinicians, and they should be informed by patients' values and goals. In many states, it is possible for a POLST to contain combinations of orders that do not translate into a cohesive care plan (eg, performing CPR but forgoing post-arrest intensive care, or delivering intensive care without antibiotics).…”