The influence of POLST on treatment intensity at the end of life: A systematic review

Abstract

Background Despite its widespread implementation, it is unclear whether Physician Orders for Life‐Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. Methods We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high‐intensity treatment (i.e., hospitalization in the last 30‐ and 90‐days of life, ICU admission in the last 30‐days of life, and number of care setting transitions in last week of life). Results Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in‐hospital death and receipt of high‐intensity treatment, particularly in pre‐hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST‐discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate‐to‐large effect sizes. Conclusion We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions

“…One study of out-of-hospital cardiac arrest in Oregon found out-of-hospital care and emergency department care generally concordant to POLST documentation [ 7 ]. A systematic literature review found moderate strength of evidence that treatment limitations documented on POLSTs, may reduce treatment intensity for patients with serious illness in the prehospital setting, however limitations in analysis did not allow an understanding of specifically when discordant interpretation occurs [ 8 ].…”

“…Despite their ubiquity, there are a very limited number of studies about EMS provider use, interpretation and application of POLST forms both in and out of cardiopulmonary arrest [4][5][6][7][8]. One survey of Emergency Medical Technicians concluded that 93% found the forms useful in cardiopulmonary arrest but only 63% found the form helpful in guiding treatment for patients with a pulse and breathing [4].…”

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

“…Translating these preferences into durable orders-that is, orders that remain in effect as the patient moves across healthcare settings and are not discontinued unless the patient or surrogate decision-maker changes them-is an effective way to honor patients' choices about their care. Together, goals of care conversations and use of durable LST orders are associated with achieving preference-sensitive care [10][11][12][13][14], a higher likelihood of out-of-hospital death, and an increase in hospice enrollment [15][16][17].…”

Emergency medical service interpretation of Physician Orders for Life‐Sustaining Treatment (POLST) in cardiopulmonary arrest

“…In a separate study by Mirarchi et al, significant variations in EMS practitioner responses to POLST forms and case scenarios demonstrated underlying confusion in the understanding of the Pennsylvania POLST 7 . One systematic literature review found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness in the prehospital setting; however, limitations in analysis do not allow an understanding of specifically when discordant interpretation occurs 9 …”