Physician Orders For Life-Sustaining Treatment Paradigm Research Articles

POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care

POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. Programs based on the POLST paradigm are used in virtually every state under names that include POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), and these forms are used in the care of hundreds of thousands of geriatric patients every year. Although POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition, some nursing homes and residential care settings use POLST to document CPR preferences for all residents, resulting in potentially inappropriate use with patients who are ineligible because they are too healthy. This article focuses on reasons that POLST is used as a default code status order form, the risks associated with this practice, and recommendations for nursing homes to implement appropriate use of POLST.

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.

Improving POLST Utilization for Seriously Ill Patients at a Tertiary Care, Academic Oncologic Hospital (TH371B)

•Describe the barriers to implementation of the POLST paradigm.•Describe initial first steps at their own institutions to improve POLST documentation for critically ill oncology patients at a tertiary cancer center. Oncologic patients go through multiple heath care transitions at the end of life. Often, goals of care discussions are initiated but communication of the conversation across settings is challenging. The Physician Orders for Life Sustaining Treatment (POLST) offers the means to successfully communicate patient's preferences across care settings. We sought to improve the usage of the POLST for oncologic patients admitted to various oncologic units at a tertiary cancer center, specifically for patients who reported their preferences for end of life care to be No CPR (DNR). In our first PDSA cycle we conducted a survey of the oncologic Advance Practice Providers (APPs) regarding barriers to POLST completion. They reported lack of familiarity with the POLST, not completing the POLST at the time of the initial conversation and forgetting to do it before discharge. Based on this, we completed a brief education on how to complete the POLST. We also made POLST forms readily accessible for all staff. At the end of the first cycle, POLST completion rates increased from 23% to 32%. As part of our second cycle, we attempted to create reminders to encourage the APPs to complete POLSTs for DNR patients. We sent biweekly patient specific emails to the APPs identifying all the patients who were DNR. However, POLST completion rates did not increase. As part of the third cycle, we again brainstormed with the APPs about continued barriers; their biggest limitations were not knowing patient's preferences regarding other components of the POLST and having to pick up the conversation from another provider. We developed a brief communication tool to utilize the information they had to complete part of the POLST and leave the rest blank. After the last PDSA cycle, the POLST completion rates increased to 46%. Increasing POLST documentation is a multipronged approach utilizing education, frequent reminders and ongoing feedback.

The Pearls of Physician Orders for Life Sustaining Treatment (POLST): Translating Patient Decisions into Treatment Orders

Since the Physician Orders for Life Sustaining Treatment (POLST) Paradigm began in 1991, POLST has become utilized throughout the United States. POLST includes the national POLST Paradigm as well as state and regional programs and their specific POLST orders. Yet many nurses may not have received the education needed for POLST implementation. This article seeks to honor individual preferences through advance care planning (ACP) by providing an understanding of POLST, which documents individual treatment wishes as medical orders. In the article the authors discuss advance care planning, advance directives, changes in patient status, and the inception and description of POLST. They distinguish POLST from DNR orders, compare POLST to advance directives, and describe the roles of registered and advanced practice nurses. Additionally, they consider studies that have endorsed the POLST paradigm, and share POLST paradigm pearls as well as possible paradigm pitfalls.

No DNR Tattoo for Me, Thanks

No DNR Tattoo for Me, Thanks

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

To assess to which extent Physician Orders for Life-Sustaining Treatment (POLST) reflect patients' preferences of care at the end of life. Two independent researchers interviewed hospitalized adult patients for whom one of their physicians would not be surprised if the patient died within one year. One interviewer followed an adapted version of the “POLST conversation” script produced by the Coalition for Compassionate Care of California and the other followed the approach proposed by Sudore & Fried for advance care planning conversations. Patients were classified as belonging to one of four groups according to their preferences of care at the end of life as assessed during each interview: 1) comfort care only, 2) limited treatment, 3) full treatment for a limited period of time, 4) full treatment for an unlimited period of time. We tested the hypothesis that the agreement between those interviews would yield a weighted kappa coefficient of at least 0.75. Sixty-two patients were included in the study. Mean age was 62 years (SD: 14y) and 21 (34%) patients were women. Median number of years of schooling was 5 years (IQR 4-11). The second interview happened within 1 to 3 days after the first interview. Median score at the Palliative Performance Scale was 70% (IQR 50-80%). The raw proportion of agreement regarding the classification of patients concerning their treatment preferences at the end of life was 95.2%, with a kappa coefficient of 0.89 (95% CI: 0.77-1.00). We provide evidence supporting the POLST paradigm as a means to translate patients' preferences of care into medical orders consistent with those preferences.

Revisiting Comfort Care

Revisiting Comfort Care

Medical Decisions: Who Should Get to Decide?

Medical Decisions: Who Should Get to Decide?

Surrogate Preferences on the Physician Orders for Life-Sustaining Treatment Form.

The purpose of this study is to compare treatment preferences of patients to those of surrogates on the Physician Orders for Life-Sustaining Treatment (POLST) forms. Data were collected from a sequential selection of 606 Massachusetts POLST (MOLST) forms at 3 hospitals, and corresponding electronic patient health records. Selections on the MOLST forms were categorized into All versus Limit Life-Sustaining Treatment. Multivariable mixed effects (grouped by clinician) logistic regression models estimated the impact of using a surrogate decision maker on choosing All Treatment, controlling for patient characteristics (age, severity of illness, sex, race/ethnicity), clinician (physician vs non-physician), and hospital (site). Surrogates signed 253 of the MOLSTs (43%). A multivariable logistic regression model taking into consideration patient, clinician, and site variables showed that surrogate decision makers were 60% less likely to choose All Treatment than patients who made their own decisions (odds ratio = 0.39 [95% confidence interval = 0.24-0.65]; p < .001). This model explained 44% of the variation in the dependent variable (Pseudo-R2 = 0.442; p < .001); mixed effects logistic regression grouped by clinician showed no difference between the models (LR test = 4.0e-13; p = 1.00). Our study took into consideration variation at the patient, clinician, and site level, and showed that surrogates had a propensity to limit life-sustaining treatment. Surrogate decision makers are frequently needed for hospitalized patients, and nearly all states have adopted the POLST. Researchers may want study decision-making processes for patients versus surrogates when the POLST paradigm is employed.

Cross-Cultural Adaptation of the Physician Orders for Life-Sustaining Treatment Form to Brazil.

The Physician Orders for Life-Sustaining Treatment (POLST) paradigm is considered one of the most important strategies to respect patients' values at the end of life in the United States. The cross-cultural adaptation of POLST entailed several methodological considerations, which may be informative for international researchers who may also consider bringing POLST to their countries as a means to promote care at the end of life that is consistent with patients' preferences. To report the methods and outcome of the cross-cultural adaptation of the POLST form to Brazil. Cross-cultural adaptation study. Twenty physicians and 10 patients at a university hospital participated in the pilot tests. The cross-cultural adaptation process included choosing which existing POLST form(s) to use as a source, deciding the intended reading level, which healthcare professionals should be allowed to sign the form, and consultation with attorneys, bioethicists, and members of the National POLST Paradigm Task Force. Pilot tests occurred in two stages using different approaches. First, 20 physicians were trained about POLST and asked for any unclear aspects related to the form. Second, trained investigators completed POLST forms after engaging in advance care planning conversations with 10 hospitalized patients or patients' surrogates. This report provides a basis for future cross-cultural adaptations of POLST to other countries. The authors hope such new adaptations will broaden the possibilities of research using POLST and also may promote wider provision of care at the end of life that is consistent with patients' preferences.

Well-Meaning Cheerleading Can Throw the Game for PA/LTC Residents

Well-Meaning Cheerleading Can Throw the Game for PA/LTC Residents

Knowing Quality When You See It

Knowing Quality When You See It

The Role of Advanced Practice Registered Nurses in the Completion of Physician Orders for Life-Sustaining Treatment.

Background: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms.Objective: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms.Design: Cross-sectional.Setting/subjects: 226,101 Oregon POLST Registry forms from 2010 to 2015.Measurements: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA).Results: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign.Conclusions: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.

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.

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.

Factors Associated With Implementation of the POLST Paradigm: Results From a Survey of Florida Physicians

To investigate physicians' awareness and attitudes regarding the Physician Orders for Life-Sustaining Treatment (POLST) concept and to identify barriers and opportunities for its expansion. Cross-sectional questionnaire, using electronic survey instrument. Community. 212 physicians from three Florida medical associations and the Florida State University College of Medicine clinical faculty responded to the survey. Of those, 67.9% were familiar with the concept of POLST. Data were collected using a web-based survey, completed in June-July 2012, consisting of qualitative and quantitative questions. Most (95.8%) agreed or strongly agreed that it was a physician's responsibility to discuss end-of-life care and treatment options with patients. Satisfaction with current advanced directives was highly variable. However, a consensus about potential benefits of POLST exists, including assisting the discussion of end-of-life care, decreasing unwanted treatment, and lowering costs. More than 70% of respondents reported they would be more likely to use the POLST form if provided civil and criminal immunity; however, data analysis rendered the apparent association statistically insignificant. Qualitative data were also collected in the form of respondents' recommendations and additional comments. Physicians vary in their knowledge and opinions regarding the POLST paradigm. Broad opportunities may exist to improve physician knowledge and attitudes toward POLST. Dissemination of educational materials to physicians involved in the end-of-life planning process may increase physician support and use of POLST.

The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is designed to improve end-of-life care by converting patients' treatment preferences into medical orders that are transferable throughout the health care system. It was initially developed in Oregon, but is now implemented in multiple states with many others considering its use. An observational study was conducted in order to identify potential legal barriers to the implementation of a POLST Paradigm. Information was obtained from experts at state emergency medical services and long-term care organizations/agencies in combination with a review of relevant state law.

Integrating POLST into Palliative Care Guidelines: A Paradigm Shift in Advance Care Planning in Oncology

Because predicting and outlining guidance for all possible scenarios is difficult, advance directives are rarely sufficiently precise to dictate patient preferences in specific situations as a disease progresses. Nonetheless, advance care planning is an essential process that should begin at the time of diagnosis, if not already initiated, to ensure that all patient and family rights are preserved. Communicating effectively with the patient and family and having the patient designate a surrogate decision-maker are critical. Attention must be paid to resolving conflicts among patient values and preferences and those of family and the health care team. Patient-centered goals for care and expectations should be elicited at first assessment and reassessed frequently as conditions change. As a disease progresses, advance directives are rarely precise enough to predict all possible scenarios and outline guidance for care. Therefore, for patients with advanced metastatic cancer and a potential life expectancy of less than 1 year, converting patient-centered treatment goals into actionable medical orders while the patient maintains capacity is a more effective way to ensure that patient preferences are honored. Physician Orders for Life-Sustaining Treatment (POLST) and similar medical order forms provide explicit direction about resuscitation status ("code status") if the patient is pulseless and apneic. POLST also includes directions about additional interventions the patient may or may not want. A decade of research in Oregon has proved that the POLST Paradigm Program more accurately conveys end-of-life preferences that are more likely to be followed by medical professionals than traditional advance directives alone.