Physician Orders For Life-Sustaining Treatment Program Research Articles

The influence of POLST on treatment intensity at the end of life: A systematic review.

Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.

Impact of the Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the Nursing Home Resident's Place of Death.

The Physician Orders for Life-Sustaining Treatment (POLST) program was developed to enhance quality of care delivered at End-of-Life (EoL). Although positive impacts of the POLST program have been identified, the association between a program maturity status and nursing home resident's likelihood of dying in their current care settings remain unanswered. This study aims to evaluate the impact of the POLST program maturity status on nursing home residents' place of death. Using multiple national-level datasets, we examined total 595,152 residents and their place of death. The result showed that the long-stay residents living in states where the program was mature status had 12% increased odds of dying in nursing homes compared that of non-conforming status. Individuals residing in states with developing program status showed 11% increase in odds of dying in nursing homes. The findings demonstrate that a well-structured and well-disseminated POLST program, combined with a continued effort to meet high standards of quality EoL care, can bring out positive health outcomes for elderly patients residing in care settings.

Impact of Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the U.S. Nursing Home Resident's Place of Death (TH311D)

•Identify impact of POLST program usage, specifically different maturity status of the program and associated outcomes in nursing home residents, for short and long-stay residents.•Discuss predictors of nursing home deaths, classified by resident level and facility level predictors. The Physician Orders for Life-Sustaining Treatments (POLST) program was developed to enhance quality of care delivered at end-of-life (EoL). Although positive effects of POLST program use on dying individual's EoL care have been identified, the association between a state's POLST program maturity status and nursing home (NH) resident's place of death is unknown. Examine the impact of state-level POLST program maturity status on elderly NH residents' place of death. The POLST program data were linked to the following national-level datasets: Minimum Data Set 3.0, Vital Statistics Data, Medicare Chronic Conditions File, Certification and Survey Provider Enhanced Reports, and Area Health Resource File. Stratifying residents on long-stay and short-stay, we used descriptive statistics and multivariate logistic regression models to examine the impact of POLST maturity status on nursing home residents' place of death. Controlling for individual and contextual variables, long-stay residents living in states where the POLST program was mature had 20% increased odds of dying in NHs (OR: 1.20; CI 1.02-1.43) compared to those in states with non-conforming status. Residents in states with endorsed or developing POLST status also had greater odds of dying in NHs (OR: 1.09; CI 0.98-1.21 endorsed; OR: 1.12; CI 1.02-1.24 developing) compared to the residents in states with non-conforming status. No significant difference was noted for short-stay residents. Higher POLST maturity status was associated with greater likelihood of dying in NHs among long-stay nursing home residents. Our findings demonstrate that a well-structured advance care planning program such as POLST enhances care outcomes among elderly patients living in NHs.

Improving Advanced Care Planning through Physician Orders for Life-Sustaining Treatment (POLST) Expansion across the United States: Lessons Learned from State-Based Developments.

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is an effective advance care planning tool. However, barriers to implementation persist. In the United States, POLST program development occurs at the state-level. Substantial differences between states has left POLST implementation largely unstandardized. No peer-reviewed studies to date have evaluated state-based POLST program development over time. To assess and learn from the successes and barriers in state-based POLST program development over time to improve the reach of POLST or similar programs across the United States. An exploratory, prospective cohort study that utilized semistructured telephone interviews was conducted over a 3-year period (2012-2015). Stakeholder representatives from state POLST coalitions (n = 14) were repeatedly queried on time-relevant successes, barriers, and innovations during POLST program development with levels of legislative and medical barriers rated 1 to 10. Interviews were transcribed and analyzed using techniques grounded in qualitative theory. All coalition representatives reported continuous POLST expansion with improved outreach and community partnerships. Significant barriers to expansion included difficulty in securing funding for training and infrastructure, lack of statewide metric systems to adequately assess expansion, lack of provider support, and legislative concerns. Medical barriers (mean [standard deviation]: 5.0 [0.2]) were rated higher than legislative (3.0 [0.6]; P < .001). POLST programs continue to grow, but not without barriers. Based on the experiences of developing coalitions, we were able to identify strategies to expand POLST programs and overcome barriers. Ultimately the "lessons learned" in this study can serve as a guide to improve the reach of POLST or similar programs.

A Tool to Assess Patient and Surrogate Knowledge About the POLST (Physician Orders for Life-Sustaining Treatment) Program

ContextIt is especially important that patients are well informed when making high-stakes, preference-sensitive decisions like those on the Physician Orders for Life-Sustaining Treatment (POLST) form. However, there is currently no way to easily evaluate whether patients understand key concepts when making these important decisions. ObjectivesTo develop a POLST knowledge survey. MethodsExpert (n = 62) ratings of key POLST facts were used to select items for a POLST knowledge survey. The survey was administered to nursing facility residents (n = 97) and surrogate decision-makers (n = 112). A subset (n = 135) were re-administered the survey after a standardized advance care planning discussion to assess the scale's responsiveness to change. ResultsThe 19-item survey demonstrated adequate reliability (α = 0.72.). Residents' scores (x = 11.4, standard deviation 3.3) were significantly lower than surrogate scores (x = 14.7, standard deviation 2.5) (P < 0.001). Scores for both groups increased significantly after administration of a standardized advance care planning discussion (P < 0.001). Although being a surrogate, age, race, education, cognitive functioning, and health literacy were significantly associated with higher POLST Knowledge Survey scores in univariate analyses, only being a surrogate (P < 0.001) and being white (P = 0.028) remained significantly associated with higher scores in multivariate analyses. ConclusionThe 19-item POLST Knowledge Survey demonstrated adequate reliability and responsiveness to change. Findings suggest the survey could be used to identify knowledge deficits and provide targeted education to ensure adequate understanding of key clinical decisions when completing POLST.

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.

The Problems With Physician Orders for Life-Sustaining Treatment.

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.

Critique of the Washington State POLST

The Washington State POLST (physician orders for life- sustaining treatment) program was developed during the early 1990s in an effort to honor patients’ end-of-life treatment plans, specifically, to prevent emergency medicine technicians and emergency room personnel from administering excessive, harmful emergency medical treatment. Consequently, unlike advance directives and living wills, a POLST provides legal authority for emergency medical personnel not to initiate CPR (cardiopulmonary resuscitation). POLST documents are designed to be universal and portable, regardless of the particular health care setting, and their directives must be followed as standing physician orders. Since then, the department, in conjunction with the state medical association, composed the POLST in use today. However, these two bodies extended the legislature’s intent beyond defining patient wishes for resuscitation during emergency medical treatment. Had the document remained limited to the legislature’s original, narrow focus, many of the problems we now encounter with POLST would not occur.

Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature.

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

Nurses' knowledge and comfort levels using the Physician Orders for Life-sustaining Treatment (POLST) form in the progressive care unit

Many patients are admitted to the hospital with an active Physician Orders for Life-sustaining Treatment (POLST) Form; however, not all registered nurses (RNs) are familiar with the form or comfortable with initiating a discussion about end-of-life care. Evidence indicates that an education program increases RNs' knowledge and utilization of the POLST form. The purpose of this evidence-based practice project was to answer the question: among the RNs in a progressive care unit (PCU), does implementing a formal evidence-based practice POLST program compared to current practice increase RNs' knowledge and comfort level using the POLST form? A pre-post education survey was used. Results indicated a POLST education program increased PCU RNs' knowledge and comfort level in using the POLST form. It is recommended to include POLST form education for PCU RNs in workplace education programs.

Validation of Physician Orders for Life‐Sustaining Treatment: Electronic Registry to Guide Emergency Care

Validation of Physician Orders for Life‐Sustaining Treatment: Electronic Registry to Guide Emergency Care

The POLST Program: A Retrospective Review of the Demographics of Use and Outcomes in One Community Where Advance Directives Are Prevalent

Determine the use and utility of the Physician Orders for Life-Sustaining Treatment (POLST) program in a community where powers of attorney for health care (POAHCs) are prevalent. A retrospective review of medical record and death certificate data of 400 adults who died between September 1, 2007, and March 31, 2008, in the La Crosse County, Wisconsin community. Demographic and cause-of-death data were collected from death certificates. Information about POAHC, POLST forms, and medical treatments provided in the last 30 days of life were abstracted from decedents' medical records. Sixty-seven percent of decedents had a POLST form, whereas 22% had POAHC alone. In comparison with decedents with POAHC alone, decedents with a POLST form were significantly older (83 versus 77 years, p<0.001), more likely to die in a nursing home than in a hospital (p<0.001), and more likely to die from a terminal or chronic illnesses (97%). Decedents with POLST orders for higher levels of medical treatment received more treatment, and in only two cases was there evidence that treatment was discrepant with POLST orders. In 31% of all POLST forms, the person appointed in the POAHC consented to the POLST orders. POLST can be a highly effective program to ensure that patient preferences are known and honored in all settings. POAHCs are valuable because they identify appropriate surrogates when patients are incapacitated.

The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form

To evaluate the consistency between treatments provided and Physician Orders for Life-Sustaining Treatment (POLST) orders. Retrospective chart abstraction. Stratified, random sample of 90 nursing facilities in Oregon, Wisconsin, and West Virginia. Eight hundred seventy living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Chart data about POLST form orders and related treatments over a 60-day period were abstracted. Decision rules were created to determine whether the rationale for each treatment was consistent with POLST orders. Most residents (85.2%) had the same POLST form in place during the review period. A majority of treatments provided to residents with orders for comfort measures only (74.3%) and limited antibiotics (83.3%) were consistent with POLST orders because they were primarily comfort focused rather than life-prolonging, but antibiotics were provided to 32.1% of residents with orders for no antibiotics. Overall consistency rates between treatments and POLST orders were high for resuscitation (98%), medical interventions (91.1%), and antibiotics (92.9%) and modest for feeding tubes (63.6%). In all, POLST orders were consistent with treatments provided 94.0% of the time. With the exception of feeding tubes and antibiotic use in residents with orders for no antibiotics, the use of medical treatments was nearly always consistent with POLST orders to provide or withhold life-sustaining interventions. The POLST program is a useful tool for ensuring that the treatment preferences of nursing facility residents are honored.

A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life‐Sustaining Treatment Program

To evaluate the relationship between two methods to communicate treatment preferences (Physician Orders for Life-Sustaining Treatment (POLST) program vs traditional practices) and documentation of life-sustaining treatment orders, symptom assessment and management, and use of life-sustaining treatments. Retrospective observational cohort study conducted between June 2006 and April 2007. A stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia. One thousand seven hundred eleven living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Life-sustaining treatment orders; pain, shortness of breath, and related treatments over a 7-day period; and use of life-sustaining treatments over a 60-day period. Residents with POLST forms were more likely to have orders about life-sustaining treatment preferences beyond cardiopulmonary resuscitation than residents without (98.0% vs 16.1%, P<.001). There were no differences between residents with and without POLST forms in symptom assessment or management. Residents with POLST forms indicating orders for comfort measures only were less likely to receive medical interventions (e.g., hospitalization) than residents with POLST full treatment orders (P=.004), residents with traditional do-not-resuscitate orders (P<.001), or residents with traditional full code orders (P<.001). Residents with POLST forms were more likely to have treatment preferences documented as medical orders than those who did not, but there were no differences in symptom management or assessment. POLST orders restricting medical interventions were associated with less use of life-sustaining treatments. Findings suggest that the POLST program offers significant advantages over traditional methods to communicate preferences about life-sustaining treatments.

Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status.

Program was designed to communicate resident/surrogate treatment preferences in the form of medical orders. To assess statewide nursing facility use of the Physician Orders for Life-Sustaining Treatment (POLST) and to identify the patterns of orders documented on residents' POLST forms. Telephone survey; on-site POLST form review. Oregon nursing facilities. One hundred forty-six nursing facilities in the telephone survey; 356 nursing facility residents aged 65 and older at seven nursing facilities in the POLST form review. A telephone survey; onsite POLST form reviews. In the telephone survey, 71% of facilities reported using the POLST program for at least half of their residents. In the POLST form review, do-not-resuscitate (DNR) orders were present on 88% of POLST forms. On forms indicating DNR, 77% reflected preferences for more than the lowest level of treatment in at least one other category. On POLST forms indicating orders to resuscitate, 47% reflected preferences for less than the highest level of treatment in at least one other category. The oldest old (> or = 85, n=167) were more likely than the young old (65-74, n=48) to have orders to limit resuscitation, medical treatment, and artificial nutrition and hydration. The POLST program is widely used in Oregon nursing facilities. A majority of individuals with DNR orders requested some other form of life-extending treatment, and advanced age was associated with orders to limit treatments.

The Physician Orders for Life-Sustaining Treatment program: Oregon emergency medical technicians' practical experiences and attitudes.

To evaluate emergency medical technicians' (EMTs) experiences with the Physician Orders for Life-Sustaining Treatment (POLST) program and learn about attitudes regarding its effectiveness. Anonymous survey mailed to a stratified random sample. Tri-County Portland, Oregon, area. A total of 572 Oregon EMT respondents (out of 1,048 surveys) were included in the analysis. Survey questions about experiences with the POLST form and opinions about POLST. Respondents were mostly male (76%) and paramedics (66%). Most respondents (73%) had treated a patient with a POLST, and 74% reported receiving education about POLST. EMTs reported that POLST, when present, changed treatment in 45% of cases. Seventy-five percent of the respondents agreed that the POLST form provides clear instructions about patient preferences, and 93% agreed that the POLST form is useful in determining which treatments to provide when the patient is in cardiopulmonary arrest. Fewer (63%) agreed that the form is useful in determining treatments when the patient has a pulse and is breathing. Most respondents have experience with the POLST program. EMTs find the POLST form useful and often use it to change treatment decisions for patients.