Use of the Physician Orders for Life‐Sustaining Treatment Program in the Clinical Setting: A Systematic Review of the Literature

Abstract

The Physician Orders for Life-Sustaining Treatment (POLST) form is a palliative care tool that contains standardized, actionable medical orders. It is designed to ensure that patient treatment preferences are elicited, communicated, and honored throughout the healthcare system. A systematic review of the literature was conducted to evaluate what is currently known about the POLST program and identify directions for future research. Twenty-three research studies focused on POLST use in the clinical setting were identified. A majority of studies have been conducted all or in part in Oregon, with chart review the most frequently used methodology. Research suggests that POLST is most commonly used in older, white patients who are near the end of life. A nonphysician facilitator usually prepares the POLST form for the physician to review and sign. The orders documented on POLST reflect a wide degree of individualization, with only approximately one-third of patients having orders reflecting the lowest level of treatment in all POLST form sections. Clinicians have generally positive attitudes regarding use of POLST yet report a wide range of challenges. POLST alters treatment in a way that is consistent with orders. However, evidence that POLST reflects patient or surrogate treatment preferences is lacking. Research is needed to evaluate the quality of POLST decisions, explore the experiences of patients and their surrogates, develop decision-support tools, improve clinician education, and assess the effect of POLST on care outcomes through intervention and population-based studies.

Do-not-attempt-resuscitation (DNAR) orders: understanding and interpretation of their use in the hospitalised patient in Ireland. A brief report

“…Physician Orders for Life-Sustaining Treatment is a geriatric palliative care tool used in the USA that contains individualised medical orders conveying the patient’s treatment preferences when approaching end of life 11. It aims to ensure care plans on treatment decisions, and resuscitation status is documented in the patient’s medical record and honoured 12 13.…”

Palliative care in patients with heart failure

“…Physician (or Medical) Orders for Life-Sustaining Treatment (POLST/MOLST) programs, the Institute for Healthcare Improvement conversation project, the efforts of the Coalition to Transform Advanced Care, and the "five wishes" advance directive of the Aging with Dignity organization are widely used despite the absence of compelling evidence that they improve patient outcomes. 115 Fortunately, some data are emerging. The Palliative Care in Heart Failure (PAL-HF; NCT01589601) trial is a prospective, controlled, unblinded, single center study of an interdisciplinary palliative care intervention in 200 patients with advanced heart failure estimated to have a high likelihood of mortality or readmission.…”

The Quality of Physician Orders for Life-Sustaining Treatment Decisions: A Pilot Study

“…16 In this study, characteristics of the facilitator, including training and profession, were not assessed, although research suggests that inadequate healthcare provider training about POLST is a challenge. 9 Exploration of these factors and their relationship to discordance may help identify how best to maximize POLST decision quality. Finally, there is no information available about the rate of discordance between advance care planning documentation and current treatment preferences in a non-POLST-using sample.…”

“…8 Several studies have established that POLST orders are associated with the kind of treatments provided to patients near the end of life, including hospitalization and the use of cardiopulmonary resuscitation (CPR). 9 Only a few small studies have evaluated aspects of POLST decision quality. Exploratory studies have found rates of discordance between current preferences and POLST orders ranging from 9% to 29%, [10][11][12] but method issues limit the generalizability of study findings.…”

“…Exploratory studies have found rates of discordance between current preferences and POLST orders ranging from 9% to 29%, [10][11][12] but method issues limit the generalizability of study findings. 9 There are no studies evaluating patient or surrogate knowledge about POLST. To assess and develop interventions to improve POLST decision quality, research is needed to determine how well existing POLST orders reflect current, informed treatment preferences and what factors influence concordance between existing orders and current preferences.…”