Orders For Life-Sustaining Treatment Research Articles

Using the POLST Paradigm to Honor Patient Wishes Across the Care Continuum: Presenting a Comprehensive Toolkit Designed to Help Health Care Professionals and Facilities Implement the POLST Paradigm (FR431)

•Review advance care planning and define the differences between advance directives and the POLST Paradigm.•Identify challenges to POLST Paradigm implementation in nursing home, hospice, primary care offices and hospitals.•Illustrate appropriate clinician training, public education, policies and procedures in nursing homes, hospice and primary care offices to ensure patient POLST Paradigm orders are elicited, known and honored. A key recommendation from the Institute of Medicine’s (IOM) Report Dying in America is to “encourage states to develop and implement a Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in accordance with nationally standardized core requirements.” The National POLST Paradigm sets those core requirements and works to ensure that individuals with serious advanced illness or frailty not only have access to POLST Paradigm forms but to professionals who understand the value of POLST and are trained to have meaningful goals of care conversations to elicit and document patient treatment wishes properly on a POLST Paradigm form, as well as professionals who will honor them. Since its inception in 1994, the POLST Paradigm has grown exponentially and now exists, at some level, in 49 states, creating an intense need for education and resources to help facilities and professionals appropriately use POLST Paradigm Forms. Used appropriately, these actionable medical order forms potentially avoid unwanted hospitalizations and emergency department visits and achieves the triple aim. Patients have peace of mind that their wishes are known and will be honored during a medical emergency. In this concurrent session, a toolkit created in partnership with the Pew Charitable Trusts will be presented. Using POLST to Honor Patient Wishes Across the Care Continuum will help facilities implement the Paradigm by addressing the needs of specific patient populations and professionals in primary care offices, hospitals, nursing homes and hospice facilities. In addition to educating about the benefits and value of the POLST Paradigm (including how it differs and complements advance directives as well as how it fits within advance care planning), the toolkit provides setting-specific resources for POLST Paradigm implementation to address the specific needs of implementing POLST in different types of care facilities.

生命維持治療に関する医師による指示書（Physician Orders for Life-sustaining Treatment, POLST）とDo Not Attempt Resuscitation（DNAR）指示

生命維持治療に関する医師による指示書（Physician Orders for Life-sustaining Treatment, POLST）は，事前指示の長い実践経験の延長上に米国で提唱された概念であり，指示内容に心停止時に心肺蘇生をしないDo Not Attempt Resuscitation（DNAR）を包含している。日本集中治療医学会倫理委員会は，DNAR指示の誤解と誤用が多い本邦においてPOLSTに基づくDNAR指示が可能かについて検討を加えた。POLST運用基盤は本邦では脆弱であり，急性期医療領域で合意形成がないPOLSTを検証なく導入し運用することに危惧がある。DNAR指示の正しい理解と運用が先決案件であり，現時点でPOLST（DNAR指示を含む）の使用は推奨できないと結論した。

Quality of Physician Orders for Life-Sustaining Treatment Forms Completed in Nursing Homes.

The physician orders for life-sustaining treatment (POLST) form allows seriously ill individuals to express their preferences for end-of-life treatments. Despite increased POLST use, little is known about the quality of completed forms. We examined the quality of POLST forms prepared for nursing home residents, including whether they had required signatures and clinically consistent care preferences. We conducted a chart review of POLST forms for a sample of nursing home residents in California. We completed POLST audits for 938 residents in 13 nursing homes in Los Angeles. We recorded whether POLST forms were signed by both the patient (or proxy) and the physician, and whether the patient's treatment choices regarding resuscitation and medical intervention were consistent, as required by the California form. Overall, 69.6% of audited POLST forms had at least one indicator of poor quality. Most lacked a required signature (15.8% lacked a physician signature and 17.4% lacked a patient/proxy signature) and 5.6% had conflicting treatment preferences. We found 30.4% of POLST forms for nursing home residents were not complete or documented clinically contradictory treatment preferences. Improvement in the quality of POLST forms is needed.

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

Physician Orders for Life-Sustaining Treatment (POLST) forms are used to document patient treatment preferences as medical orders. Prior research demonstrates that use of POLST alters medical treatments in a way that is consistent with the POLST orders. However, there are minimal data about the quality of POLST decisions, including whether they reflect the current preferences of well-informed patients. Evaluate the quality of POLST decisions. Chart abstraction; interviews. Nursing home residents and healthcare agents of incapacitated nursing home residents (n = 28). Characteristics of the POLST conversation were assessed. Brief vignettes were used to assess knowledge about how POLST orders guide medical treatment. Current treatment preferences were elicited and compared with the patient's POLST orders to assess discordance. A majority (59%) of participants recognized the POLST form. Participants were generally accurate in their knowledge of how POLST orders guide treatment concerning cardiopulmonary resuscitation (CPR) (68%), antibiotics (74%), and artificial nutrition (79%), but less so for medical interventions (50%). Current treatment preferences were initially discordant with one or more POLST orders for 64% (18/28) of participants, but half of these discordances were resolved with further discussion (e.g., participant agreed with the existing order). Discordance by treatment decision was as follows: CPR (7%), level of medical intervention (18%), antibiotics (21%), and artificial nutrition (11%). Discordance between current preferences and POLST orders is complex. Interventions are needed to support high-quality POLST decisions that are informed and concordant with current preferences.

Implementation of a Novel Electronic Health Record-Embedded Physician Orders for Life-Sustaining Treatment System.

In April 2015, Oregon Health & Science University (OHSU) deployed a web-based, electronic medical record-embedded application created by third party vendor Vynca Inc. to allow real-time education, and completion of Physician Orders for Life Sustaining Treatment (POLST). Forms are automatically linked to the Epic Systems™ electronic health record (EHR) patient header and submitted to a state Registry, improving efficiency, accuracy, and rapid access to and retrieval of these important medical orders. POLST Forms, implemented in Oregon in 1992, are standardized portable medical orders used to document patient treatment goals for end-of-life care. In 2009, Oregon developed the first POLST-only statewide registry with a legislative mandate requiring POLST form signers to register the form unless the patient opts out. The Registry offers 24/7 emergency access to POLST Forms for Emergency Medical Services, Emergency Departments, and Acute Care Units. Because POLST is intended for those nearing end of life, immediate access to these forms at the time of an emergency is critical. Delays in registering a POLST Form may result in unwanted treatment if the paper form is not immediately available. An electronic POLST Form completion system (ePOLST) was implemented to support direct Registry submission. Other benefits of the system include single-sign-on, transmission of HL7 data for patient demographics and other relevant information, elimination of potential errors in form completion using internalized logic, built-in real-time video and text-based education materials for both patients and health care professionals, and mobile linkage for signature capture.

Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

ObjectivesWhat patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. ProceduresMOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the “other instructions” section were submitted to content analysis. ResultsSixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for “comfort measures only” seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. ConclusionsPatients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study.

Increasing advance care planning (ACP) among older adults is a national priority. Documentation of ACP in the electronic health record (EHR) is particularly important during emergency care. We sought to characterize completion and availability of ACP among a subset of older patients at an academic emergency department (ED) with an integrated EHR. In this cross-sectional study, patients were eligible if aged ≥80 years or aged 65-79 with ≥1 indicator of high risk for short-term mortality. Patient-reported completion of ACP and availability of ACP documentation in the EHR were assessed. Among study patients (n = 104), 59% reported completing some form of ACP: living will 52%, heathcare power of attorney 54%, do not resuscitate 38%, and medical orders for scope of treatment or physician orders for life-sustaining treatment 6%. Whites were more likely to report having some form of ACP than minorities (66% vs. 37%, p < 0.01), as were patients aged ≥80 years than those aged 65-79 (79% vs. 44%, p < 0.01). Only 13% of all patients had either a current code status or any other current ACP documentation in the EHR. Among patients whose primary care provider uses the same EHR system as the study ED, only 19% had a current code status or any other ACP documentation in the EHR. In a sample of older ED patients likely to benefit from ACP, few patients had documented end-of-life care preferences in the EHR.

Overcoming Legal Impediments to Physician Orders for Life-Sustaining Treatment.

The Physician Orders for Life-Sustaining Treatment (POLST), otherwise known as the POLST paradigm, represents the next generation in end-of-life (EOL) planning for certain patients who wish to exercise prospective control over their own medical treatment in their final days. As is true for any physician treatment orders, a POLST is written in consultation with the patient or patient's surrogate. There are a number of practical impediments to widespread adoption and implementation of the POLST paradigm in medical practice. One of these impediments has to do with some physicians' anxiety about potential negative legal repercussions they might suffer for writing or following a patient's POLST; this is the focus of the present article. After describing the POLST paradigm and physicians' anxieties about it, this article argues that the feared potential negative legal consequences of writing or following a patient's POLST are not well founded. Instead of succumbing to legal and ethical paralysis, resulting in the failure to integrate the POLST paradigm robustly into practice, physicians should feel comfortable under current and developing law to write and honor POLSTs for appropriate patients. This article explains the basis for such physician comfort.

The Role of Health Care Provider Goals, Plans, and Physician Orders for Life-Sustaining Treatment (POLST) in Preparing for Conversations About End-of-Life Care

The Physician Orders for Life-Sustaining Treatment (POLST) is a planning tool representative of an emerging paradigm aimed at facilitating elicitation of patient end-of-life care preferences. This study assessed the impact of the POLST document on provider goals and plans for conversations about end-of-life care treatment options. A 2 (POLST: experimental, control) × 3 (topic of possible patient misunderstanding: cardiopulmonary resuscitation, medical intervention, artificially administered nutrition) experimental design was used to assess goals, plan complexity, and strategies for plan alterations by medical professionals. Findings suggested that the POLST had little impact on plan complexity or reaction time with initial plans. However, preliminary evidence suggested that the utility of the POLST surfaced with provider responses to patient misunderstanding, in which differences in conditions were identified. Significant differences in goals reported as most important in driving conversational engagement emerged. Implications for findings are discussed.

Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer: A Retrospective Analysis.

To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer. We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral. Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC. We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.

Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach.

The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.

Survey on Clinician Perceptions and Practices Regarding Goals of Care Conversations.

Early conversations between clinicians and patients about goals of care may improve patients' quality of life and prevent nonbeneficial care near the end of life, but these conversations are limited in frequency and scope. To address this issue, clinicians are increasingly asked to use standardized medical order forms, like the Medical Orders for Life-Sustaining Treatment (MOLST), to document end-of-life conversations and to help ensure that patients' wishes are realized. In kind, the Centers for Medicare and Medicaid Services recently decided to reimburse physicians as well as nurse practitioners and physician assistants for these conversations. To explore physicians' and advanced practitioners' (APs') attitudes and behaviors around initiating and documenting goals of care conversations and to identify targets for improvement. Online survey administered between October 1, 2014 and February 20, 2015. Physicians (n = 2492) and APs (n = 336) at an urban academic medical center. Clinicians' perceptions and self-reported behaviors regarding goals of care conversations and the Massachusetts MOLST form. We found that 44.0% of physicians and 33.0% of APs reported that they discussed goals of care with all patients with serious, life-limiting illness (p < 0.001). APs were more likely than physicians to report awareness of MOLST forms (55.1% vs. 45.1%, p < 0.001) but less likely to feel comfortable making recommendations on end-of-life care (25.3% vs. 41.0% recommending against resuscitation, p < 0.001; 35.1% vs. 55.7% recommending for resuscitation, p < 0.001). These findings suggest the need to educate physicians and empower APs to facilitate goals of care conversations and use standardized forms, as well as an opportunity for interdisciplinary collaboration.

Interactive Online Module Failed to Improve Sustained Knowledge of the Maryland Medical Orders for Life-Sustaining Treatment Form.

Legal documents similar to the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form requiring physician endorsement are increasingly used by critically ill patients. To evaluate whether an interactive, online training module on completion and interpretation of the MOLST form leads to a sustained increase in knowledge among house staff. Pre/post survey of 329 house staff at Johns Hopkins Hospital who admit and discharge patients between June 2014 and July 2015. House staff were encouraged to complete a voluntary, interactive, online educational module on completing and interpreting MOLST forms. Participants received $25 for accessing the module and $10 for completing each survey. The primary outcome was the change in the number of questions answered correctly on the post- versus presurvey comparing house staff who viewed the module for at least 20 minutes with house staff who never viewed or never completed the module. Overall, 329 (69%) house staff completed the knowledge assessment survey both before and after the module was available, and 201 (61%) of these house staff completed the voluntary module. The median score on the presurvey conducted in July and August of 2014 was 14 out of 21 (interquartile range [IQR] 12, 16). The median (IQR) score on the postsurvey conducted in May and June of 2015 was 15 out of 21 (13, 17). The median (IQR) change in score among those who spent at least 20 minutes completing the module was 1 question (-1, 3), and among those who never viewed or never completed the module it was also 1 (IQR -1, 2). The postsurvey was completed a median (IQR) of 59 (52, 62) days after viewing the module. After adjusting for years of postgraduate clinical training, self-reported baseline experience completing MOLST forms, and self-reported responsibility for discharging patients, viewing the module for at least 20 minutes was associated with a nonsignificant increase in score of 0.41 questions (95% confidence interval, -0.25, 1.06; P = 0.23). An interactive, online educational module had no effect on trainee knowledge of completing and interpreting MOLST forms approximately 2 months after completion. Information conveyed via online modules alone may have minimal sustained impact on house staff knowledge.

Emergency Physicians' Experience with Advance Care Planning Documentation in the Electronic Medical Record: Useful, Needed, and Elusive.

For patients' preferences to be honored, emergency department (ED) physicians must be able to find and use advance care planning (ACP) information in the electronic medical record (EMR). ED physicians' experiences with ACP EMR documentation and their documentation needs are unknown. We surveyed 70 ED physicians (81% response rate) from a tertiary and county ED. Our primary outcome was confidence finding and using ACP EMR documentation (percentage reporting very/extremely on a five-point Likert scale). Secondary outcomes included frequency of use and perceived usefulness of types of ACP documentation. Suggestions for improvement were analyzed using thematic content analysis. Participants' mean age was 36 years (± 9) and 54% were women. Thirty-one percent reported being very/extremely confident they could find ACP EMR documentation, and 55% felt very/extremely confident they could use it to care for patients. Yet 74% needed it ≥1 time/week and 43% ≥5 times/week. Participants reported code status orders (90%), Physician Orders for Life Sustaining Treatment (POLST) (86%), and durable power of attorney for health care (78%) as very/extremely useful, followed by values statements (31%), oral directives (34%), and living wills (37%). ED physicians wanted highly visible ACP information, "on the main screen." EMR systems are not optimized to provide critical ACP information to ED physicians who lack confidence finding or using ACP EMR documentation to care for patients. Dedicated ACP information on the EMR home screen and tailored training may be needed to help ED providers find, use, and discuss ACP documentation to provide care aligned with patients' goals.

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents.

Physician Orders for Life-Sustaining Treatment (POLST) is a tool that facilitates the elicitation and continuity of life-sustaining care preferences. POLST was implemented in California in 2009, but how well it disseminated across a large, racially diverse population is not known and has implications for end-of-life care. To evaluate the use of POLST among California nursing home residents, including variation by resident characteristics and by nursing home facility. Observational study using California Minimum Data Set Section S. A total of 296,276 people with a stay in 1,220 California nursing homes in 2011. The proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; change in POLST use during 2011; and POLST completion and unsigned forms within nursing homes. During 2011, POLST completion increased from 33 to 49 % of California nursing home residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status. There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. Variation in POLST completion among nursing homes far exceeded that attributable to resident characteristics with 40 % of facilities having ≥80 % of long-stay residents with a completed POLST, while 20 % of facilities had ≤10 % of long-stay residents with a completed POLST. Thirteen percent of nursing home residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid. Statewide nursing home data show broad uptake of POLST in California without racial disparity. However, variation in POLST completion among nursing homes identifies potential areas for quality improvement.

Medicare and Advance Planning: The Importance of Context.

In January 2016, a long-delayed Medicare change took effect. The Medicare program will now reimburse doctors for time they spend talking with patients about end-of-life care. This is the move that Sarah Palin and other Affordable Care Act critics said would authorize government "death panels" to decide whether older Americans should live or die. Today virtually no one buys into Palin's death panel rhetoric. But many people do think the Medicare change is a big deal. Representative Earl Blumenauer, a Democrat from Oregon who sponsored the original ACA reimbursement proposal, lauded the Medicare provision as "a turning point in end-of-life care." Others are not so sure about that. After all, laws promoting advance care planning have existed for decades. The federal Patient Self-Determination Act of 1990 and the many court decisions and state laws supporting advance care planning have had relatively little impact. Similarly, legal recognition of physician orders for life-sustaining treatment as advance planning instruments have not produced the improvements that were predicted. And from a broad perspective, advance care planning is a small piece of the puzzle. The effort to improve end-of-life care must take into account the limitations of advance decision-making, as well as the overriding importance of the general standard of care for terminally ill patients.

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years.

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.

Stone Throwing in the Glass House.

A small girl with a unique genetic syndrome lies in bed since birth. Her brain does not work. She is in a persistent vegetative state. Recurrent seizures punctuate her intractable epilepsy. She shows no meaningful interaction. Her breathing is insufficient. Upper airway obstruction, repeated aspiration events, chronic lung disease, and scoliosis make her struggle to breathe. Her parents never wanted her to suffer. Two years ago, they agreed to a Physician Orders for Life-Sustaining Treatment (POLST). Their daughter would not undergo resuscitation. Death did not come, however. With meticulous medical care, her body grew. Her breathing worsened. Offered either palliation or a tracheostomy tube, her parents chose “trach.” With easier breathing, the girl expended fewer calories. She continued gastrostomy tube feeds and gained 10 pounds in 3 months. Now she is rehospitalized with respiratory distress. Her weight rises another 2 pounds. We put off calorie reduction for the outpatient setting. For the first time, we discharge the family home with a mechanical ventilator. Our collective health-care efforts have set up a protracted course whose likely end will come in overwhelming sepsis or ARDS, rather than allowing natural death with palliative care. How many ethical issues were raised by this case? I count more than 40 (Table ​(Table11).

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Implementation of Medical Orders for Life-Sustaining Treatment.

When an outpatient in a northeastern cancer institute requested a Medical Orders for Life-Sustaining Treatment (MOLST) form, the state's approved resuscitation form in all settings, none were available. A project was undertaken to institute MOLST forms into policy and routine practice. Research supports early discussions of end-of-life care in patients with cancer and the use of MOLST as an effective tool. The purpose of this article is to discuss the initiation and facilitation of MOLST implementation into practice and policy at a cancer institute. Introducing, overcoming resistance to, piloting, and adopting MOLST in an oncology setting is reported and explained based on the three stages of Lewin's Theory of Planned Change. A small pilot of MOLST with palliative care providers demonstrated the feasibility and suitability of using MOLST in the oncology setting. MOLST was adopted into policy and routine practice at the cancer institute.