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Objectives The POLST (Physician Orders for Life-Sustaining Treatment) program is designed to ensure patients’ treatment preferences are honored by documenting preferences as medical orders. The goal of this study was to evaluate the consistency between treatments provided and POLST orders. Design Retrospective chart abstraction. Setting Stratified, random sample of 90 nursing facilities in Oregon, Wisconsin, and West Virginia. Participants 870 living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Measurements 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. Results 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. However, 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%), antibiotics (92.9%), and modest for feeding tubes (63.6%). In all, POLST orders were consistent with treatments provided 94.0% of the time. Conclusion 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. Findings suggest the POLST program is a useful tool for ensuring that the treatment preferences of nursing facility residents are honored.

OBJECTIVES: 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. DESIGN: Retrospective observational cohort study conducted between June 2006 and April 2007. SETTING: A stratified, random sample of 90 Medicaideligible nursing facilities in Oregon, Wisconsin, and West Virginia. PARTICIPANTS: One thousand seven hundred eleven living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. MEASUREMENTS: 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. RESULTS: 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%, Po.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 5.004), residents with traditional do-not-resuscitate orders (Po.001), or residents with traditional full code orders (Po.001). CONCLUSION: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.

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.

atients living with serious illness suffer both physically and psychologically. Although many factors contribute, including disease characteristics, quality of care, social determinants, and systems issues, wide consensus exists that poor communication by health care professionals plays a central role. 1(pp117-219) Physical and psychological suffering worsens when patients do not fully understand their illness, prognosis, and treatment options and when clinicians have not sufficiently elicited patients' values. Consequently, patients may receive medical care inconsistent with their goals. 2 Inadequate communication also leads to higher use of invasive care near death, shorter hospice stays, lower patient quality of life at the end of life, and worse bereavement outcomes for family and caregivers. 3 Poor-quality communication not only affects patients and families but also contributes to clinician burnout, a troubling outcome given current workforce shortages. 4 Although considerable research explores the effect of communication on these outcomes, many questions remain. Setting a clear research agenda would move the field forward. Since the late 1980s, the primary approach to addressing poor communication and unwanted care for patients approaching the end of life has been to promote advance directive completion. Despite legislation encouraging advance directives and numerous dissemination efforts, the outcomes have been disappointing. Initiatives that focus on advance directives alone have changed little in the quality of the experience for seriously patients and families. 1 Many additional aspects of communication that mediate outcomes in serious illness are insufficiently addressed, including emotion, prognostic awareness, goals of care, spirituality and existential issues, and costs of care. 5-8 Furthermore, effective interventions have not been disseminated widely into practice. IMPORTANCE Poor communication by health care professionals contributes to physical and psychological suffering in patients living with serious illness. Patients may not fully understand their illness, prognosis, and treatment options or may not receive medical care consistent with their goals. Despite considerable research exploring the role of communication in this setting, many questions remain, and a clear agenda for communication research is lacking. OBSERVATIONS Through a consensus conference and subsequent activities, we reviewed the state of the science, identified key evidence gaps in understanding the impact of communication on patient outcomes, and created an agenda for future research. We considered 7 broad topics: shared decision making, advance care planning, communication training, measuring communication, communication about prognosis, emotion and serious illness communication, and cultural issues. We identified 5 areas in which further research could substantially move the field forward and help enhance patient care: measurement and methodology, including how to determine communication quality; mechanisms of communicati...

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Objectives: 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. Methods: 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. Results: 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. Conclusions: 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.