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.