Emergency doctors and paramedics commonly misinterpret documents for end-of-life care choices

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I wasn’t too surprised to learn that a pair of new studies finds that emergency care providers vary in their understanding of a type of medical order intended to communicate seriously ill patients’ choices for life-sustaining treatments.

Coincidentally, part two of my extensive interview with Nancy Berlinger, Ph.D., a research scholar at The Hastings Center, appears today in Covering Health. Berlinger stressed the need for more conversations and better physician education on end-of-life and palliative care.

The studies show “significant confusion” among emergency physicians and prehospital care providers in interpreting the universal end-of-life care documents, called Physicians Orders for Life Sustaining Treatment (POLST). “Our data suggest that POLST orders can be confusing for Pennsylvania emergency physicians, and likely for physicians nationwide,” concludes lead author Dr. Ferdinando L. Mirarchi of UPMC Hamot, Erie, Pa., and colleagues.

How Well Do Emergency Providers Interpret POLST Documents?

POLST orders are a growing national model for seriously ill patients to document their choices regarding end-of-life-care. The POLST form is a one-page, brightly colored document–varying in color and formatting from state to state–that serves as an active medical order across healthcare settings. The POLST lets patients state their choices regarding resuscitation, either “do not resuscitate” (DNR) or full cardiopulmonary resuscitation (CPR); and other treatments, with options for full treatment, limited treatment, or “comfort measures” only.

Mirarchi and colleagues surveyed Pennsylvania emergency department physicians and prehospital care providers (paramedics and emergency medical technicians) regarding their understanding and interpretation of POLST forms. Both groups were presented with various clinical scenarios of critically ill patients, with POLST forms specifying different options for resuscitation and treatment.

Rates of “consensus”– defined as 95 percent agreement — were assessed in the different situations. Surveys were completed by 223 emergency physicians and 1,069 prehospital care providers.

In the majority of the clinical scenarios, for both emergency physicians and prehospital providers, the results fell well short of consensus benchmarks. “Both studies reveal variable understandings and variable repsonses as far as treating critically ill patients with the available POLST combinations of choices,” Mirarchi commented.

Consensus Reached Only for Patients Choosing CPR and ‘Full Treatment’

Even when the POLST specified “DNR” with “comfort measures” only, ten percent of emergency physicians and 15 percent of prehospital providers indicated they would still perform CPR. The only situation to show 95 percent agreement was when the POLST form specified “CPR” and “full treatment.”

Older and more experienced physicians were less likely to choose “DNR” in certain situations. In both studies, responses were similar for participants with and without previous POLST training.

Intended to address the limitations of “living wills” and advance directives for end-of-life care, “The POLST provides medical orders that are immediately actionable and to be universally honored across various healthcare settings,” according to the study authors.  POLST is currently in use in 20 states; other states are in the process of adopting the standards.  The POLST is generally used by seriously ill patients for whom sudden death within the next year would not be unexpected. However, some states and institutions have adopted its use outside of the specified indications.

According to this Wall Street Journal article, POLST orders may help to ensure that patients receive care consistent with their treatment goals. Additionally, they are very effective at limiting life-saving care and may prevent avoidable readmissions to hospitals.

However, it’s still not clear whether that the POLST combinations truly equate with informed consent by patients. Reports show that the majority of POLST forms are prepared by non-medical personnel, and then become actionable with a physician’s signature.

The new study raises further concern by showing that emergency care providers vary in their interpretation of POLST documents. In some situations, respondents indicate that they would resuscitate when they should be expected to withhold life-saving treatment. Conversely, some respondents would withhold treatment when they would be expected to provide life-saving care.

“Our results reveal clinical and safety issues related to confusion” with POLST documents, the researchers concluded. They call for continued research, standards, and education to help ensure “patient autonomy and appropriate care” regarding life-sustaining treatments for people with serious illnesses and limited life expectancy. They have developed a patient safety checklist to be used at the time of resuscitation to remind providers to confirm and follow expressed treatment choices with an individualized plan of care for the patient.

 

photo credit: Emergency Room via photopin (license)

It’s Heart Health Month

1 and 99.

Two numbers to remember – this month and every month

Heart Disease is the #1 cause of death in the U.S. for both men and women.

99 percent of us need to improve our heart health.

heart-stroke

Take care of your heart. It’s the best Valentine’s present you can give to yourself – and to those who love you.

Check out the American Heart Association’s website for more information on heart disease and stroke – and how you can avoid becoming another statistic.

Many Women with Breast Cancer Have Poor Knowledge About Their Condition

A new analysis finds that many women with breast cancer lack knowledge about their illness, with minority patients less likely than white patients to know and report accurate information about their tumors’ characteristics. This further supports the need to better educate women about their health conditions so they can make more informed treatment decisions.The findings appear in the online version of CANCER, the peer-reviewed journal of the American Cancer Society.

radiotherapy

courtesy Gerry Lauzon CC license

Although previous studies have examined general cancer knowledge, this was the first study that looked at whether women actually know and understand the details about their own cancers. Rachel Freedman, MD, MPH, of the Dana-Farber Cancer Institute in Boston, and her colleagues surveyed 500 women with breast cancer to see how knowledgeable they were about their own cancers, including the tumor stage, grade, and receptor status (breast cancer subtype). While 32 percent to 82 percent reported knowing each of the tumor characteristics that they were asked about, only 20 percent to 58 percent actually reported these characteristics correctly.

Black and Hispanic women were often less likely than white women to know their cancer characteristics, even after adjusting for socioeconomic status and health literacy. 

“Our results illustrate the lack of understanding many patients have about their cancers and have identified a critical need for improved patient education and provider awareness of this issue,” said Freedman in a statement. “Improving patients’ understanding about why a particular treatment is important for her individual situation may lead to more informed decisions and better adherence to treatment.”  Understanding tumor characteristics and the reasons for personalized treatment recommendations could also improve a woman’s trust, confidence, and satisfaction with her cancer treatment providers, Freedman added.

Each year in the United States, more than 200,000 women get breast cancer and more than 40,000 women die from the disease, according to the Centers for Disease Control and Prevention. 

More information about breast cancer can be found through many research and advocacy organizations, including

Don’t Worry, Be Happy. It’s Good for Your Heart.

happyfacePeople who have upbeat outlooks on life are twice as likely to have better cardiovascular health, than those whose outlooks are less rosy, according to a recently published study that looked at links between optimism and heart health.

 “Individuals with the highest levels of optimism have twice the odds of being in ideal cardiovascular health compared to their more pessimistic counterparts,” said lead author Rosalba Hernandez, a professor of social work at the University of Illinois. “This association remains significant, even after adjusting for socio-demographic characteristics and poor mental health.”

Participants’ cardiovascular health was assessed using seven metrics: blood pressure, body mass index, fasting plasma glucose and serum cholesterol levels, dietary intake, physical activity and tobacco use – the same metrics used by the American Heart Association to define heart health. These steps are also targeted by the AHA in its Life’s Simple 7 public awareness campaign.

In accordance with AHA’s heart-health criteria, the researchers allocated 0, 1 or 2 points –representing poor, intermediate and ideal scores, respectively – to more than 5,100 adult participants on each of the seven health metrics. Points were then added up to obtain a total cardiovascular health score. Participants’ total health scores ranged from 0 to 14, a higher total score meant better health.

Participants ranged in age from 45-84. They completed surveys that assessed their mental health, levels of optimism, and physical health, based upon self-reported existence of arthritis, liver and kidney disease. Individuals’ total health scores increased along with their levels of optimism.

Researchers found that the most optimistic people were 50 and 76 percent more likely to have total health scores in the intermediate or ideal ranges, respectively. The association between optimism and cardiovascular health was even stronger when sociodemographic characteristics such as age, race and ethnicity, income and education status were factored in. People who were the most optimistic were twice as likely to have ideal cardiovascular health, and 55 percent more likely to have a total health score in the intermediate range, the researchers found.

Optimists had significantly better blood sugar and total cholesterol levels than their counterparts. They also were more physically active, had healthier body mass indexes and were less likely to smoke. The findings may be of clinical significance, given that a 2013 study indicated that a one-point increase in an individual’s total-health score on the LS7 was associated with an 8 percent reduction in their risk of stroke, Hernandez said.

“At the population level, even this moderate difference in cardiovascular health translates into a significant reduction in death rates,” Hernandez said.

Researchers believe this is the first study that examines the association of optimism and cardiovascular health in a large, ethnically and racially diverse population. Participants for the current study were 38 percent white, 28 percent African-American, 22 percent Hispanic/Latino and 12 percent Chinese. Data for the study were derived from the Multi-Ethnic Study of Atherosclerosis (MESA), an ongoing examination of subclinical cardiovascular disease that includes 6,800 people from six U.S. regions.

Fast Food Still Too High in Salt, Fat and Calories

wikimedia fast foodAre you planning to reduce or eliminate fast food from your diet this year? You probably should.

Despite the epidemic of obesity in the U.S., there’s been little change in portion sizes and meal formulation between 1996 and 2013.

An analysis of calorie, sodium, saturated fat and trans fat content of popular menu items served at three national fast-food chains by scientists at Tufts University U.S.D.A. Human Nutrition and Research Center on Aging, found that average calories, sodium, and saturated fat stayed relatively constant, although at high levels. The exception was a consistent decline in the trans fat of fries.

The studies appear in the current issue of Preventing Chronic Disease, a journal of the Centers for Disease Control and Prevention. “There is a perception that restaurants have significantly expanded their portion sizes over the years, but the fast food we assessed does not appear to be part of that trend,” said lead researcher Alice H. Lichtenstein, D.Sc., director of the Cardiovascular Nutrition Laboratory at the USDA HNRCA. “Our analysis indicates relative consistency in the quantities of calories, saturated fat, and sodium. However, the variability among chains is considerable and the levels are high for most of the individual menu items assessed, particularly for items frequently sold together as a meal, pushing the limits of what we should be eating to maintain a healthy weight and sodium intake.”

Calories in a large cheeseburger meal, with fries and a regular cola beverage, ranged from 1144 to 1757 over the years and among restaurants. Lichtenstein said this represents anywhere from 57 to 88 percent of the approximately 2000 calories most people should consumer daily. “That does not leave much wiggle room for the rest of the day,” she said.

According to the authors’ 2013 data, calorie content of the cheeseburger meal among the three chains represented 65% to 80% of a 2,000 calorie per day diet and sodium content represented 63% to 91% of the recommendation. The U.S. Dietary Guidelines for Americans recommend adults limit their salt intake to a maximum of 2,300 milligrams per day. Depending on the chain, between 1996 and 2013, eating a single 4 oz. cheeseburger could have accounted for 1100 to 1450 mg of daily sodium representing 48% to 63% of target limits.

Lichtenstein and colleagues focused on the four most popular menu items: fries, cheeseburgers, grilled chicken sandwiches, and regular cola, looking for trends in portion size and nutrient content over an 18 year period. They examined 27 items including small, medium and large fries and cola beverages, a grilled chicken sandwich, and 2 oz. and 4 oz. cheeseburgers. The authors used a public database and the Internet to access the archived nutrition data.

They found only small fluctuations in calorie content and the amount of saturated fat and sodium. The notable exception was fries, which decreased first in saturated fat in 2001 and then trans fat, likely due to changes to the frying fat.

“The decline in trans fat we saw between 2005 and 2009 appears to be related to legislative efforts,” Lichtenstein said. “The success of New York City’s trans fat ban and others like it, suggest it is worth pursuing these types of approaches because they make the default option the healthier option. Of course, it is important to note that the healthier option in terms of fat does not translate into lower calories or less salt.”

According to the reports, fast food sales remain strong despite public health campaigns. This contributes to our epidemic of obesity and hypertension. “Restaurants can help consumers by downsizing portion sizes and reformulating their food to contain less of these over-consumed nutrients. This can be done, gradually, by cutting the amount of sodium, and using leaner cuts of meat and reduced-fat cheese,” Lichtenstein said. “From what we hear some fast-food chains are heading in that direction and also introducing new healthier options. If taken advantage of, these changes should help consumers adhere to the current dietary recommendations.”

The authors also note nutrient content varied among similar items from different chains. For example, an order of small fries could differ by as much as 110 calories and 320 mg of sodium from chain to chain. “For this reason our findings strongly suggest that public health efforts promoting reduction of calories and over-consumed nutrients need to shift from emphasizing small, medium and large portion sizes, to additional factors such as actual number of calories and the nutrient content of the items, as is increasingly becoming available at point of purchase,” Lichtenstein said. “A 100 calorie difference per day can mean about a 10 pound weight change per year.”