Explore This IssueACEP Now: Vol 34 – No 05 – May 2015
Physician orders for life-sustaining treatment (POLST) is a paradigm moving quickly across the United States and was intended to address deficiencies in the advance directive process. The movement is quickly outpacing quality research, educational standards, and regulatory processes. This POLST movement is becoming an unfunded mandate very similar to the mandate proposed back in 1990 with the passage of the patient’s self-determination act related to living wills and advance directives.
POLST is to be utilized in patients who are frail, elderly, and expected to die within six months to one year.1 However, states and hospital systems are becoming more liberal with utilization. Additionally, payer systems are financially incentivizing institutions to create POLST forms for many different patient populations, especially those discharged to skilled nursing or rehabilitation or admitted to hospitals for a variety of conditions. POLST is a physician order. However, it is often completed by nonmedical personnel and then signed by a physician and in some states by an advanced practice provider.2 This process, combined with payer incentives, should raise one’s level of concern with the ability of the patient to fully understand the implications and provide informed consent.
In multiple studies, POLST is very effective at minimizing unnecessary resuscitation, predicting location of death, and preventing unwarranted hospital admission.
Regardless of the aforementioned concerns, POLST has proven useful. In multiple studies, POLST is very effective at minimizing unnecessary resuscitation, predicting location of death, and preventing unwarranted hospital admission.3–5 Although POLST’s intended purpose is to address deficiencies in the advance directive process, advance directives have also proven useful in providing patient and family fulfillment, decreased Medicare spending, decreased in-hospital deaths, and increased utilization of hospice.6
In March 2015, the Journal of Patient Safety published a pair of The Realistic Interpretation of Advance Directives (TRIAD) studies. TRIAD-VI–Emergency Medicine Physician and TRIAD-VII–Emergency Medical Services understanding of POLST in Pennsylvania indicate that there is confusion among providers with POLST utilization in the setting of critical illness.7,8 In reality, this may indicate confusion across the nation, as there is very little practice variation with respect to end-of-life care in the practice of emergency medicine and prehospital care throughout the United States.
The studies indicate, based upon provider understanding in the setting of critical illness, that patients are at risk to be both over and underresuscitated.7,8 These rates appear to be similar to what was previously published in TRIAD-III–Nationwide Assessment of Living Wills and Do Not Resuscitate (DNR) Orders.9