Are We Getting What We Really Want? A Systematic Review of Concordance Between Physician Orders for Life-Sustaining Treatment (POLST) Documentation and Subsequent Care Delivered at End-of-Life

Abstract

Background: Physician Orders for Life-Sustaining Treatments (POLST) is an advance care planning (ACP) tool that is designed to facilitate End-of-Life (EoL) care discussions between a medical provider and a terminally ill patient. It is often used as a tool to translate care wishes into a medical order, which can be honored across healthcare settings. With an increased utilization of the POLST paradigm in various healthcare settings along with continued dissemination across the nation, it is critical to examine whether documented wishes on POLST are concordant with subsequent care delivered. Purpose of this article was to examine concordance rate between POLST and subsequent care delivered in any care settings and communities. Design: Systematic review. Results: Of 1,406 articles identified, 10 articles met inclusion criteria. Together, included studies represent 5,688 POLST forms reviewed from individuals residing in a total of 126 nursing care facilities, 9 elderly care centers, 4 community settings, and 2 hospitals. Preference for cardiopulmonary resuscitation and actual delivery/ withholding of resuscitation was the most observed intervention in study of concordance (n = 8). It is also where highest concordance rate (97.5%) was reported. Seven studies compared care provided during EoL and the level of medical intervention requested on POLST forms (91.17% concordance). Preference to use artificial nutrition/ hydration, and actual delivery was 93.0% (n = 4 studies), and antibiotics use preference and delivery was 96.5% (reported in 4 studies). Conclusion: Published literature evidence suggests that EoL care wishes documented on POLST forms were largely concordant with subsequent care delivered. Additional research is needed to evaluate concordance between POLST documentation and care received among POLST users, who experienced multiple care transitions across healthcare settings, or across state during EoL care journey.

Care preferences in physician orders for life sustaining treatment in California nursing homes

“…29 Studies have demonstrated that end-of-life care wishes documented in POLST forms are largely concordant with subsequent care delivered. 30 Due to concern for potential harm from poor quality POLST completion leading to discordance between POLST orders and actual patient care preferences, 31 some have proposed limiting POLST use to only those who desire comfort-focused care with an expected clinical trajectory toward end-of-life. 29,32,33 Black, Hispanic, and Asian nursing home residents were far less likely than non-Hispanic Whites to choose lower intensity care in the study population, but were similarly or more likely to complete a POLST.…”

The Medical Orders for Scope of Treatment (MOST) form completion: a retrospective study

“…There are plenty implications for future research as we previously discussed. MOST-specific studies are needed focusing on the effectiveness and efficiency of MOST-like forms in facilitating discussions and GoC concordance [ 4 , 32 – 37 ] and holistic system of ACP processes [ 4 ]. Interventions (e.g., education for all stakeholders) may affect utilization of MOST form [ 38 ].…”

Toolkit to Increase Provider Knowledge, Comfort, and Adoption of POLST

“…[5][6][7] One study noted that patients received their preferred level of care in about 99% of the cases while another systematic review showed high concordance with cardiopulmonary resuscitation preferences and increased discordance with other interventions on the POLST form. 6,5 This suggests that individualized care planning via POLST can allow caregivers to carry out the patient's preferences. POLST form completion engages PCPs in promotion of end-of-life wishes for communitydwelling individuals.…”

“…It was noted in the literature those patients who had completed POLSTs were highly likely to have their wishes met. [5][6][7] One study noted that patients received their preferred level of care in about 99% of the cases while another systematic review showed high concordance with cardiopulmonary resuscitation preferences and increased discordance with other interventions on the POLST form. 6,5 This suggests that individualized care planning via POLST can allow caregivers to carry out the patient's preferences.…”