Conflicting Orders in Physician Orders forLife‐SustainingTreatment Forms

Abstract

BACKGROUND/OBJECTIVES Many older persons with chronic illness use Physician Orders for Life‐Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders. DESIGN Retrospective cohort study. SETTING Large academic health system. PARTICIPANTS A total of 3,123 POLST users with chronic life‐limiting illness who died between 2010 and 2015 (mean age = 69.7 years). MEASUREMENTS In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions. RESULTS Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to “attempt CPR” paired with orders for “limited interventions” or “comfort measures only”; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non‐comfort‐only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18–1.36; P < .001). CONCLUSION Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.

Care preferences in physician orders for life sustaining treatment in California nursing homes

“…Althogh POLST completion was not required in California, the high rate of completion seen in this study may be in part related to the integration of POLST completion into the MDS, a mandatory, regulatory assessment completed for all nursing home residents. Few POLST forms (<6%) had contradictory orders, consistent with prior studies examining the quality of POLST completion in other states 19–22 …”

“…Few POLST forms (<6%) had contradictory orders, consistent with prior studies examining the quality of POLST completion in other states. [19][20][21][22] POLST completion was greater among nursing home residents with more functional dependence, but was lower among those with greater cognitive impairment. This finding was noted in a prior study by this group looking only at 2011 California MDS data, 5 and is unchanged 5 years later.…”

Advance care planning by proxy in German nursing homes: Descriptive analysis and policy implications

“…The experience gained with the widely established Physician Orders for Life‐Sustaining Treatment (POLST) indicates to some extent that such concise advance care planning (ACP) is feasible 46 . In a recent study, however, 24% of POLSTs contained at least one pair of incoherent orders which may limit their effectiveness in many acute care scenarios 47 . Furthermore, even with correctly completed POLSTs, the care delivered may still turn out to be discordant with the POLSTs—in a current study to up to 38% 32,48 .…”

Factors associated with concordance between POLST orders and current treatment preferences

“…Inconsistencies between POLST orders and treatments may in part reflect an appropriate in-themoment response to discordance when it is identified 10,13,40 or a correction of conflicting orders. 44 In contrast to residents who were making decisions for themselves, surrogates were making decisions for residents who were older, sicker, and more impaired. A substantial majority (76%) of the residents for whom they were making decisions had a diagnosis of dementia and surrogates were more likely than residents to report the residents' health status had worsened over the past year.…”