Demonstrating the impact of POLST forms on hospital care requires information not contained in state registries

Abstract

Background Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging. Objectives To demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects. Design Prospective cohort study. Setting and participants Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission. Results Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10). Conclusion Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.

The influence of POLST on treatment intensity at the end of life: A systematic review

“…Among these readmissions, 112 patients (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to do‐not‐resuscitate/do‐not‐intubate order (1.2 vs. 27.1 h, p = 0.001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs. 25.4 h, p = 0.10) 52 …”

“…Among the 27,092 patients with POLST across all studies, the median sample size was 261 (IQR 145, 830). All studies were observational and included four descriptive studies, 40,44,46,51 15 retrospective cohort studies, 14,17,32–35,41–43,45,47–50,53 and one prospective cohort study 52 . There were no randomized controlled trials of POLST.…”

“…First, perhaps the greatest benefit of POLST lies upstream of the acute care setting in pre‐hospital settings or nursing homes, helping to disrupt the clinical momentum that is often initiated during medical emergencies and which may contribute to the provision of unwanted care in the hospital 32,35,61 . Second, accessibility of advance care planning documents is important in efforts to deliver goal‐concordant care, particularly for patients who are unable to speak for themselves 52 …”

“…32,35,61 Second, accessibility of advance care planning documents is important in efforts to deliver goal-concordant care, particularly for patients who are unable to speak for themselves. 52 Third, using POLST form completion as a quality metric and surrogate for high-quality communication may have unintended consequences. For instance, POLST forms are often used as a substitute for code status documentation among patients admitted to skilled nursing facilities or before elective surgeries.…”

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

“…Translating these preferences into durable orders-that is, orders that remain in effect as the patient moves across healthcare settings and are not discontinued unless the patient or surrogate decision-maker changes them-is an effective way to honor patients' choices about their care. Together, goals of care conversations and use of durable LST orders are associated with achieving preference-sensitive care [10][11][12][13][14], a higher likelihood of out-of-hospital death, and an increase in hospice enrollment [15][16][17].…”