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
Understanding POLST Is Good Practice
Emergency physician Michael Barton, MD, sings about the importance of understanding physician orders for life-sustaining treatment in his song “Good Practice.”
In the face of a quickly growing national POLST movement, we should perform more research as it relates to patient safety and provider understanding. Medical providers need to embrace POLST but be aware of its limitations. One should consider guidelines from the American Bar Association and National POLST Paradigm Task Force regarding reviewing and confirming choices elected on POLST forms.10 The use of a patient-safety checklist would be a conservative approach to individualize patient care and safety. A resuscitation pause or advance directive patient-safety checklist (see Table 1) represents an opportunity to maintain compliance with existing national recommendations and also help ensure the delivery of appropriate care.7,8,11,12
Dr. Mirarchi is medical director of the department of emergency medicine at UPMC Hamot and chair of the UPMC Hamot Physician Network in Erie, Pennsylvania.
Table 1. ABCDEs of the Living Will, DNR, or POLST13
Ask patients or surrogates to be clear as to their intentions for their advance directive (living will, DNR order, or POLST form).
Be clear as to if this is a terminal condition despite sound medical treatment or persistent vegetative state versus a treatable critical illness.
Communicate clearly if you feel the condition is reversible and treatable with a good or poor prognostic outcome.
Design a plan and discuss next steps. For example, say, “Your mom is critically ill. We can give her a trial of instituting life-sustaining care for 48 to 72 hours, and if there is no benefit, we can withdraw care and treatment.”
Explain that it’s OK to withhold care and treatment or withdraw care so long as it’s in keeping with the patients’ perceived wishes. Also, take a moment to explain the benefits of palliative care and hospice.
- Hickman SE, Nelson CA, Perrin NA, et al. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc. 2010;58:1241-1248.
- California Advocates for Nursing Home Reform. Physician orders for life sustaining treatment (“POLST”): problems and recommendations, 2010. Available at: http://www.canhr.org/reports/2010/POLST_WhitePaper.pdf. Accessed April 9, 2014.
- Fromme E, Zive D, Schmidt T, et al. Association between physician orders for life-sustaining treatment for scope of treatment and in-hospital death in Oregon. J Am Geriatr Soc. 2014;62(7):1246-1251.
- Richardson DK, Fromme E, Zive D, et al. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann Emerg Med. 2014;63:375-383.
- Schmidt TA, Zive D, Fromme EK, et al. Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST registry. Resuscitation. 2014;85:480-485.
- Nicholas LH, Langa KM, Iwashyna TJ. Regional variations in the association between advanced directives and end-of-life Medicare expenditures. JAMA. 2011;306:1447-1453.
- Mirarchi FL, Doshi AA, Zerkle SW. TRIAD VI–how well do emergency physicians understand physicians orders for life-sustaining treatment (POLST) forms? J Patient Safe. 2015;11:1-8.
- Mirarchi FL, Cammarata C, Zerkle SW. TRIAD VII–do prehospital providers understand physicians orders for life-sustaining treatment documents? J Patient Safe. 2015;1:9-17.
- Mirarchi FL, Costello E, Puller J, et al. TRIAD III: nationwide assessment of living wills and do not resuscitate orders. J Emerg Med. 2012;42:511-520.
- National POLST Paradigm Task Force. POLST legislative guide. Available at: http://www.polst.org/wp-content/uploads/2014/02/2014-02-20-POLST-Legislative-Guide-FINAL.pdf. Accessed May 16, 2014.
- Mirarchi FL. Avoid potential pitfalls of living wills, DNR, and POLST with checklists, standardization. ACEP Now. 2014;33:13.
- Mirarchi FL. A new nationwide patient safety concern related to living will, DNR orders and POLST-like documents. October 2014. Available at: http://www.npsf.org/blogpost/1158873/200782/A-New-Nationwide-Patient-Safety-Concern-Related-to-Living-Wills-DNR-Orders-and-POLST-Like-Documents. Accessed April 15, 2015.
- Mirarchi FL. Understanding Your Living Will. Omaha, Neb: Addicus Books; 2006.