The Problems With Physician Orders for Life-Sustaining Treatment.

Abstract

In 1991, physicians in Oregon developed the Physician Orders for Life-Sustaining Treatment (POLST) program to address a specific and substantive problem: due to societal defaults toward cardiopulmonary resuscitation (CPR) and life support absent orders to the contrary, many seriously ill patients receive unwanted resuscitation and hospitalization. By making physicians' orders portable, the original intent of POLST was to provide legal authority for emergency medical services personnel (ie, paramedics and emergency medical technicians) to not attempt CPR for patients who had requested that CPR be withheld. In contrast to advance directives, which provide guidance for clinicians and family members in the future if a patient were to become terminally ill or permanently unconscious, POLST enacts legally valid medical orders for current treatment. More than 30% of patients in Oregon have an active POLST at the time of death,1 and the National Quality Forum has identified POLST as a preferred palliative care practice.2 Seventeen states have implemented POLST statewide or are considering statewide implementation, and another 28 states are in the process of developing a POLST program.3 In addition to orders to attempt or not to attempt CPR (often section A of POLST documents), all state POLST documents now govern, to some extent, the scope of medical treatment to be provided if the patient has a pulse or is breathing (often section B). Common options in section B include comfort measures (which excludes transfer to a hospital), limited treatment (which excludes advanced airway management), and full treatment. All 17 states with fully developed programs include orders regarding the use of mechanical ventilation and artificial nutrition and hydration. Eight of these states also include orders regarding the use of antibiotics. A review of the 28 developing state programs suggests a very similar pattern of covered interventions. In addition to this geographical expansion, POLST has expanded beyond the out-of-hospital setting to emergency departments and other settings. Given the frequency of unwanted medical interventions provided to dying patients that gave rise to the POLST movement, concerted efforts to change the status quo are commendable. However, in this Viewpoint, we suggest that the rapid expansion of POLST programs may distract from the broader social goals of promoting informed decisions about health care options among seriously ill patients and improving the infrastructure needed to deliver high-quality care near the end of life. Given these risks and the dearth of evidence that POLST programs, as currently designed, improve care for the dying, we also suggest: (1)any further implementation of POLST programs be accompanied by a rigorous plan for evaluating their effects on processes and outcomes of care; and (2) any plans to consider POLST completion as a quality metric be halted.