Physician Orders For Life-Sustaining Treatment Forms Research Articles

Effect of outpatient physician involvement on the physician orders for life-sustaining treatment completed by hospitalists: a cross-sectional study.

Hospitalists are becoming increasingly involved in end-of-life (EOL) care decision making. They participate in the completion of physician orders for life-sustaining treatment (POLST) for patients who have not yet decided whether to proceed with life-sustaining treatment (LST) at the EOL. However, hospitalists are not physicians who have continuously treated patients in outpatient settings; hence, the continuity of care may be poor. We aimed to analyze the effect of outpatient physician involvement on the POLST completed by hospitalists. A retrospective cohort study was conducted in patients aged 18 years or older treated by hospitalists who completed POLST at Seoul National University Bundang Hospital from February 2018 to March 2020. The clinical and sociodemographic data were obtained through a medical chart review, and the differences in the characteristics of POLST were analyzed depending on the status of outpatient physician involvement. A total of 3,533 POLST forms were written, of which 175 (5.22%) were completed by the hospitalists. The proportion of POLSTs completed by hospitalists gradually increased from 2.53% in 2018 to 4.58% in 2019 and 15.9% in 2020. A total of 144 (82.3%) patients had malignancies, while 31 (17.7%) patients had non-cancer illnesses. In 47.4% of the patients, outpatient physicians were involved in completing physician's orders for LST. When the outpatient physicians were involved, more patients signed the POLST form themselves (P=0.02) and chose comfort measures only when asked to determine their preferred LST type (P=0.00). The completion of POLST by hospitalists is gradually increasing. LST was reduced when the outpatient physicians participated in the completion of POLST. Using measures to increase the involvement of outpatient providers in goal care discussions, the quality and goal concordance of EOL care can be improved.

Emergency medical service interpretation of Physician Orders for Life-Sustaining Treatment (POLST) in cardiopulmonary arrest.

ObjectivePhysician Orders for Life‐Sustaining Treatment (POLST) forms exist in some form in all 50 states. This study evaluates emergency medical service (EMS) practitioners interpretation of the POLST in cardiopulmonary arrest.MethodsThis study used a prospective convenience sample of California Bay Area EMS practitioners who reviewed 6 fictional scenarios of patients in cardiopulmonary arrest and accompanying California POLST forms. Based on the cases and POLST, EMS practitioners identified patient preference for “attempt resuscitation,” “do not attempt resuscitation/DNR,” or “unsure” and subsequently selected medical interventions (ie, chest compressions, defibrillation, and so on). They also rated their confidence in POLST use and interpretation.ResultsIn scenarios of cardiopulmonary arrest and POLST that indicated do not resuscitate (DNR)/do not attempt resuscitation (DNAR) and full treatment, only 45%–65% of EMS practitioners correctly identified the patient as DNR/DNAR. EMS practitioners were more likely to interpret the POLST correctly in scenarios where patients were DNR/DNAR but indicated selective treatment (86%; 168/196) or comfort‐focused treatment (86%; 169/196). In cardiopulmonary arrest scenarios where the patient was correctly identified as DNR/DNAR, EMS practitioners frequently selected defibrillation, advanced airway, or epinephrine as appropriate treatment. For all 6 scenarios, there was no statistical difference in response selection with level of training (emergency medical technician/paramedics) or type of EMS personnel (fire based/private).ConclusionThe POLST is a powerful tool to convey medical treatment preferences; however, there is significant variation in the interpretation and application by EMS practitioners. To improve the POLST effectiveness, the authors suggest more EMS input into POLST development, concise language that defines resuscitation, and more EMS education about clinical application.

Discussing patient preferences for levels of life-sustaining treatment: development and pilot testing of a Danish POLST form

BackgroundMedically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients’ preferences for levels of life-sustaining treatment are known and documented.MethodsThe study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners’ clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient’s values and preferences. Family members and/or nursing staff could participate. Participants’ assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation.ResultsIn total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future.ConclusionThe Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients’ preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study.

Decision-making conversations for life-sustaining treatment with seriously ill patients using a Danish version of the US POLST: a qualitative study of patient and physician experiences

Objective To explore patients’ and physicians’ perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form. Design Semi-structured interviews following a conversation about preferences for life-sustaining treatment. Setting Danish hospitals, nursing homes, and general practitioners’ clinics. Subjects Patients and physicians. Main outcome measures Qualitative analyses of interview data. Findings After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy. Conclusion Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges. KEY POINTS Conversations about preferences for life-sustaining treatment are important, but not performed systematically. When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements. Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care. Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

Patient-physician conversations about life-sustaining treatment: Treatment preferences and participant assessments.

In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients' treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form. The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making. A total of 95 patients (aged 41-95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree. The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.

Documentation of advance care planning forms in patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder characterized by progressive weakness. Survival is typically only a few years from symptom onset. The often-predictable disease course creates opportunities to complete advance care planning (ACP) forms. The Physician Orders for Life-Sustaining Treatment (POLST) is a broadly used ACP paradigm to communicate end-of-life wishes but has not been well-studied in the ALS population. In this retrospective chart review study, patients diagnosed with ALS seen between 2014 and 2018 at an academic ALS center were identified. Demographic information, clinical characteristics, and ACP data were collected. Of 513 patients identified, 30% had an ACP document. POLST forms were competed in 16.6% of patients with 73.8% of forms signed by a neurologist. Only 5.1% of patients saw a palliative care physician. Palliative care consultation was associated with having an POLST on file (P< .001). Patients with completed POLST forms were significantly more likely to have been seen in clinic more frequently (P< .001) and have a lower ALS Functional Rating Scale-Revised score on last visit (P= .005). Less than one third of patients with ALS completed an ACP document, and only a small percentage completed POLST forms. The data suggest a need for greater documentation of goals of care in the ALS population.

Association of Physician Orders for Life-Sustaining Treatment With Inpatient Antimicrobial Use at End of Life in Patients With Cancer.

BackgroundAntimicrobial utilization at end of life is common, but whether advance directives correlate with usage is unknown. We sought to determine whether Washington State Physician Orders for Life Sustaining Treatment (POLST) form completion or antimicrobial preferences documented therein correlate with subsequent inpatient antimicrobial prescribing at end of life.MethodsThis was a single-center, retrospective cohort study of adult patients at a cancer center who died between January 1, 2016, and June 30, 2019. We used negative binomial models adjusted for age, sex, and malignancy type to test the relationship between POLST form completion ≥30 days before death, antimicrobial preferences, and antimicrobial days of therapy (DOT) per 1000 inpatient-days in the last 30 days of life.ResultsAmong 1295 eligible decedents with ≥1 inpatient-day during the last 30 days of life, 318 (24.6%) completed a POLST form. Of 318, 120 (37.7%) were completed ≥30 days before death, 35/120 (29.2%) specified limited antimicrobials, 55/120 (45.8%) specified full antimicrobial use, and 30/120 (25%) omitted antimicrobial preference. Eighty-three percent (1070/1295) received ≥1 inpatient antimicrobial. The median total and intravenous (IV) antimicrobial DOT/1000 inpatient-days were 1077 and 667. Patients specifying limited antimicrobials had significantly lower total antimicrobial DOT (adjusted incidence rate ratio [IRR], 0.68; 95% CI, 0.49–0.95; P = .02) and IV antimicrobial DOT (IRR, 0.57; 95% CI, 0.38–0.86; P = .008) compared with those without a POLST.ConclusionsIndicating a preference for limited antimicrobials on a POLST form ≥30 days before death may lead to less inpatient antimicrobial use in the last 30 days of life.

A Video Decision Aid for the West Virginia POLST: A Randomized, Controlled Trial

Patients with serious medical conditions are faced with making decisions about treatments related to end-of-life care. The Physician Orders for Life Sustaining Treatment (POLST) is a document that allows patients to express preferences for four medical decisions including cardiopulmonary resuscitation, level of medical intervention, and medically administered fluids and nutrition. The purpose of the study was to develop and evaluate a video decision aid for the West Virginia POLST form. Sixty-four community-dwelling adults (50+) were recruited to participate. Participants were randomized to active control (exercise video) or intervention group (POLST video). Knowledge and decisional conflict were measured pre- and post-intervention. Participants were given a hypothetical vignette with medical information for the purpose of completing study measures. Separate MANCOVAs were conducted to explore the relation between treatment group and decisional outcomes at post-intervention for each medical decision, while controlling for numeracy and pre-intervention ratings of knowledge and decisional conflict. Results identified significant main effects of treatment group for each of the four medical decisions. Participants who viewed the video were more knowledgeable regarding CPR F(1,59) = 42.844, p<.001, medical interventions F(1,59) = 20.475, p<.001, and medically administered fluids F(1,59) = 31.004, p<.001, compared to participants assigned to the control group. Additionally, participants who viewed the video had less decisional conflict related to CPR F(1,59) = 17.892, p<.001, medical interventions F(1,59) = 31.017, p<.001, medically administered fluids F(3,56) = 11.718, p=.001, and nutrition F(1,59) = 16.411, p<.001, compared to participants in the control group. Conclusions and practical implications will be discussed.

Use of a State Registry to Compare Practices of Physicians and Nurse Practitioners in Completing Physician Orders for Life-Sustaining Treatment Forms.

Background: Understanding the role of nonphysicians in Physician Orders for Life-Sustaining Treatment (POLST) completion is limited. Objectives: To examine the role that nurse practitioners (NPs) play in POLST completion and differences between NPs and physicians in POLST orders. Design: Retrospective observational study. Setting/Subjects: A total of 3829 POLST forms submitted to the West Virginia (WV) e-Directive Registry between July 1, 2018 and June 30, 2019, which was completed by 98 NPs and 511 physicians. Measurements: POLST forms completed and orders in POLST Section A and Section B by all physicians and NPs according to practice (primary care, palliative care, hospital, and nursing home) and by palliative care physicians and NPs only. Results: NPs completed almost twice as many forms on average as physicians (9.54 ± 20.82 vs. 5.66 ± 17.18, p = 0.0064). NPs constituted 16.10% (98/609) of the clinicians writing POLST forms but completed 24.40% (935/3829) of the forms (p < 0.001). Compared with physicians' orders, a greater percentage of NP's orders was for do-not-resuscitate in Section A (87.20% vs. 72.60%, p < 0.001) and comfort measures in Section B (42.90% vs. 33.10%, p < 0.001). There was a greater percentage of NPs in palliative care practice than physicians (23.50% vs. 6.07%, p < 0.001), and palliative care NPs completed 64.20% (600/935) of the forms submitted by NPs compared with palliative care physicians who completed 17.90% (517/2894) of the forms submitted by physicians (p < 0.001). Conclusions: In WV, physician and NP POLST completion differs based on practice. NPs completed significantly more POLST forms on average and more often ordered comfort measures. NPs can play a significant role in POLST completion.

Are We Getting What We Really Want? A Systematic Review of Concordance Between Physician Orders for Life-Sustaining Treatment (POLST) Documentation and Subsequent Care Delivered at End-of-Life.

Physician Orders for Life-Sustaining Treatments (POLST) is an advance care planning (ACP) tool that is designed to facilitate End-of-Life (EoL) care discussions between a medical provider and a terminally ill patient. It is often used as a tool to translate care wishes into a medical order, which can be honored across healthcare settings. With an increased utilization of the POLST paradigm in various healthcare settings along with continued dissemination across the nation, it is critical to examine whether documented wishes on POLST are concordant with subsequent care delivered. Purpose of this article was to examine concordance rate between POLST and subsequent care delivered in any care settings and communities. Systematic review. Of 1,406 articles identified, 10 articles met inclusion criteria. Together, included studies represent 5,688 POLST forms reviewed from individuals residing in a total of 126 nursing care facilities, 9 elderly care centers, 4 community settings, and 2 hospitals. Preference for cardiopulmonary resuscitation and actual delivery/ withholding of resuscitation was the most observed intervention in study of concordance (n = 8). It is also where highest concordance rate (97.5%) was reported. Seven studies compared care provided during EoL and the level of medical intervention requested on POLST forms (91.17% concordance). Preference to use artificial nutrition/ hydration, and actual delivery was 93.0% (n = 4 studies), and antibiotics use preference and delivery was 96.5% (reported in 4 studies). Published literature evidence suggests that EoL care wishes documented on POLST forms were largely concordant with subsequent care delivered. Additional research is needed to evaluate concordance between POLST documentation and care received among POLST users, who experienced multiple care transitions across healthcare settings, or across state during EoL care journey.

To What Extent Do Physician Orders for Life-Sustaining Treatment (POLST) Reflect Patients' Preferences for Care at the End of Life?

ObjectiveTo assess whether medical orders within Physician Orders for Life-Sustaining Treatment (POLST) forms reflect patients' preferences for care at the end of life. DesignThis cross-sectional study assessed the agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation performed by an independent researcher during a single episode of hospitalization. Setting and ParticipantsInpatients at a single public university hospital, aged 21 years or older, and for whom one of their attending physicians provided a negative answer to the following question: “Would I be surprised if this patient died in the next year?” Data collection occurred between October 2016 and September 2017. MeasuresAgreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation was measured by kappa statistics. ResultsSixty-two patients were interviewed. Patients' median (interquartile range) age was 62 (56-70) years, and 21 patients (34%) were women. Overall, in 7 (11%) cases, disagreement in at least 1 medical order for life-sustaining treatment was found between POLST forms and the content of the independent advance care planning conversation. The kappa statistic for cardiopulmonary resuscitation was 0.92 [95% confidence interval (CI): 0.82-1.00]; for level of medical intervention, 0.90 (95% CI: 0.81-0.99); and for artificially administered nutrition, 0.87 (95% CI: 0.75-0.98). Conclusions and ImplicationsThe high level of agreement between medical orders in POLST forms and the documentation in an independent advance care planning conversation offers further support for the POLST paradigm. In addition, the finding that the agreement was not 100% underscores the need to confirm frequently that POLST medical orders accurately reflect patients' current values and preferences of care.

Evaluation of a Video Decision Aid to Reduce Decisional Conflict in Physician Orders for Life-Sustaining Treatment (POLST) Decision-Making.

Physician Orders for Life-Sustaining Treatment (POLST) is recommended as a preferred practice for advance care planning with seriously ill patients. Decision aids can assist patients in advance care planning, but there are limited studies on their use for POLST decisions. We hypothesized that after viewing a POLST video, decision aid participants would demonstrate increased knowledge and satisfaction and decreased decisional conflict. Pre-and postintervention with no control group. Fifty community-dwelling adults aged 65 and older asked to complete a POLST based on a hypothetical condition. Video decision aid for Sections A and B of the POLST form. Pre- and postintervention participant knowledge, decisional satisfaction, decisional conflict, and acceptability of video decision aid. Use of the video decision aid increased knowledge scores from 11.24 ± 2.77 to 14.32 ± 2.89, P < .001, improved decisional satisfaction 10.14 ± 3.73 to 8.70 ± 3.00, P = .001, and decreased decisional conflict 12 ± 9.42 to 8.15 ± 9.13, P < .001. All participants reported that they were comfortable using the video decision aid, that they would recommend it to others, and that it clarified POLST decisions. Participants endorsed the use of a POLST video decision aid, which increased their knowledge of POLST form options and satisfaction with their decisions, and decreased their decisional conflict in POLST completion. This pilot study provides preliminary support for the use of video decision aids for POLST decision-making. Future research should evaluate a decision aid for the entire POLST form and identify patient preferences for implementing POLST decision aids into clinical practice.

DNR, DNI, and DNO?

The addition of a do-not-operate (DNO) section to current medical orders for life-sustaining treatment (MOLST) and physician orders for life-sustaining treatment (POLST) medical order forms would more completely document patients' wishes for invasive interventions at the end of life. We propose a modification of the MOLST and POLST forms, in addition to hospital and electronic medical records, to include a DNO section, in addition to preexisting do-not-resuscitate (DNR) and do-not-intubate (DNI) orders, with the goal of reducing suffering from nonbeneficial surgical interventions in patients with severe illness at the end of life.

PC-FACS

PC-FACS

The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department

Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon betweenApril 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome washospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

Injured Older Adults Transported by Emergency Medical Services: One Year Outcomes by POLST Status

Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. We linked multiple data sources to EMS records, including: the Oregon POLST Registry, Medicare claims data, Oregon Trauma Registry, Oregon statewide inpatient data, and Oregon vital statistics records. We describe patient and event characteristics by POLST status at time of 9-1-1 contact, subsequent changes in POLST forms, and mortality to 12 months. Results: Of 7,055 injured older adults, 1,412 (20.0%) had a registered POLST form at the time of 911 contact. Among the 1,412 POLST forms, 390 (27.6%) specified full orders, 585 (41.4%) limited interventions, and 437 (30.9%) comfort measures only. By one year, 2,471 (35%) patients had completed POLST forms. Among the 4 groups (no POLST, POLST-full orders, POLST-limited intervention, POLST-comfort measures), Injury Severity Scores were similar. Mortality differences were present by 30 days (5.0%, 4.6%, 8.0%, and 13.3%, p < 0.01) and were greater by one year (19.5%, 23.9%, 35.4%, and 46.2%, p < 0.01). Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up.

Evaluation of the Interrater Reliability of End-of-Life Medical Orders in the Physician Orders for Life-Sustaining Treatment Form

Despite its spread in much of the United States and increased international interest, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm still lacks supporting evidence. The interrater reliability of the POLST form to translate patients' values and preferences into medical orders for care at the end of life remains to be studied. To assess the interrater reliability of the medical orders documented in POLST forms. This cross-sectional study was conducted in a public university hospital in southeastern Brazil. Two independent researchers interviewed the same patients or decision-making surrogates (n = 64) during a single episode of hospitalization within a time frame of 1 to 7 days. Eligible participants were hospitalized adults aged 21 years or older who were expected to remain hospitalized for at least 4 days and whose attending physician responded no to the question, Would I be surprised if this patient died in the next year? Data collection occurred between November 1, 2015, and September 20, 2016, and first data analyses were performed on October 3, 2016. Interrater reliability as measured by κ statistics. Of the 64 participants interviewed in the study, 53 (83%) were patients and 11 (17%) were surrogates. Patients' mean (SD) age was 64 (14) years, and 35 patients (55%) and 8 surrogates (73%) were women. Overall, in 5 cases (8%), disagreement in at least 1 medical order for life-sustaining treatment was found in the POLST form, changing from the first interview to the second interview. The κ statistic for cardiopulmonary resuscitation was 0.92 (95% CI, 0.80-1.00); for level of medical intervention, 0.89 (95% CI, 0.76-1.00); and for artificially administered nutrition, 0.92 (95% CI, 0.83-1.00). The high interrater reliability of the medical orders in POLST forms appears to offer further support for this advance care planning paradigm; in addition, the finding that this interrater reliability was not 100% underscores the need to ensure that patients or their surrogates have decision-making capacity and to confirm that the content of POLST forms accurately reflects patients' current treatment preferences.

Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan.

Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.

The Comparison of State POLST Forms: Scope of Life-Sustaining Treatment (S869)

1.Analyze the structure and categories included in state POLST form to compare to a form in a neighboring state, and be able to state two similarities and two differences between forms.2.Explain the potential implications of excluding a “Goals of Care” section from POLST forms, both from the perspective of the provider and the patient. Physician Orders for Life-Sustaining Treatment (POLST) is a portable medical order that delineates patients’ and/or surrogates’ care preferences. Currently, all states have POLST programs, either endorsed or in development. However, we do not know how consistent the treatments in POLST forms are across the states. 1.Identify the variations in life-sustaining treatments offered in state POLST forms.2.Discuss the potential implications of variability in state POLST forms. State POLST forms were retrieved in May 2018 from official websites or email correspondence with state program coordinators. Data on the presence of Goals of Care, Cardiopulmonary Resuscitation (CPR), Medical Interventions, Artificial Nutrition, Antibiotics, and other treatment categories were extracted and analyzed using descriptive statistics. Of the 45 state POLST forms reviewed, only six included a goals-of-care section. POLST forms included two to eight treatment categories: one with two categories (CPR and medical interventions), 17 with three categories (CPR, medical interventions, and artificial nutrition), 11 with four categories (CPR, medical interventions, artificial nutrition, and antibiotics), and 16 with four or more categories of other treatments. The CPR category had CPR and do-not-resuscitate choices in all forms. In 41 forms, the Medical Interventions category had choices of Comfort Measures Only, Limited Interventions, and Full Treatment. Forty-four forms had the Artificial Nutrition category with three choices (None, Defined Period, and Long-Term) with or without additional choices (e.g., hydration, parenteral nutrition). Seventeen forms included the Antibiotics category with two to four choices. Other treatment categories included dialysis, transfer to hospital, and blood transfusion. Although there is some consistency in POLST forms, significant variation exists in treatment categories and choices.

No DNR Tattoo for Me, Thanks

No DNR Tattoo for Me, Thanks