The POLST Paradigm and Form: Facts and Analysis

Brugger, Christian; Breschi, Louis C.; Hart, Edith Mary; Kummer, Mark; Lane, John I.; Morrow, Peter T.; Smith, Franklin L.; Toffler, William L.; Beffel, Marisa; Brehany, John F.; Buscher, Sara; Marker, Rita L.

doi:10.1179/0024363913z.00000000027

Cited by 17 publications

(10 citation statements)

References 26 publications

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“…One of the proposals to achieve better granularity of the advanced live support directives included creation of the scale of treatment intensity: terminal, palliative, usual, and intensive with CPR included in the last group only (24). Other much more detailed advance directives as the Medical Orders for Life-Sustaining Treatment (MOLST) and Physician Order for Life-Sustaining Treatment (POLST) were proposed (25, 26). We intend to study further the impact of these detailed advanced directives on ICU outcomes from 2008 to date.…”

Section: Discussionmentioning

confidence: 99%

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU*

Fuchs

Anstey

Feng

et al. 2017

Critical Care Medicine

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Objectives We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs. Design Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008. Intervention None. Patients Two cohorts were defined: patients with do not resuscitate advance directives on day 1 of ICU admission and a control group comprising patients with no limitations of level of care on ICU day 1 (full code). Measurements and Main Results The primary outcome was mortality at 28 days after ICU admission. Of 19,007 ICU patients, 1,239 patients (6.5%) had a do-not-resuscitate order on the first day of ICU admission and survived 48 hours in the ICU. We matched those do-not-resuscitate patients with 2,402 patients with full-code status. Twenty-eight day and 1-year mortality were both significantly higher in the do-not-resuscitate group (33.9% vs 18.4% and 60.7% vs 40.2%; p < 0.001, respectively). Conclusion Do-not-resuscitate status is an independent risk factor for ICU mortality. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status.

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Section: Discussionmentioning

confidence: 99%

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU*

Fuchs

Anstey

Feng

et al. 2017

Critical Care Medicine

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“…What differentiated the POLST from other advance care planning tools (e.g., living wills or advance directives) was that documented care wishes on POLST forms become pre-signed actionable, and transferrable medical orders that can be honored across healthcare settings. 3 Often printed in a distinctive bright pink background, POLST form contains 3 key sections; Section A: Cardiopulmonary Resuscitation (CPR), Section B: Medical Interventions (Comfort Measures Only: primary goal of maximizing comfort; Limited Treatment: goal of treating medical condition with basic medical treatments, but no intubation or ventilation; and Full Treatment: all medical treatments including breathing machine with goal to prolong life by all medically effective means), Section C: Artificially Administered Nutrition. It is noteworthy that medical interventions pertinent to EoL care (e.g., use of Intensive Care Unit (ICU), transfer to hospital) are listed under section B.…”

Section: Introductionmentioning

confidence: 99%

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

Tark

Song

Parajuli

et al. 2020

Am J Hosp Palliat Care

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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.

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“…Although discussing CPR at all represents a huge cultural shift, 11 , 38 there is still scope for significant improvement: we should be evaluating ways to engage with individuals to think about what treatments they might want before they become ill. Contextualising CPR decisions within overall goals of care has been helpful in achieving this in both the US 39 and the UK. 19 …”

Section: Discussionmentioning

confidence: 99%

Themes and variations: An exploratory international investigation into resuscitation decision-making

2016

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BackgroundDo Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made in hospitals throughout the globe. International variation in clinicians' perception of DNACPR decision-making and implementation and the factors influencing such variation has not previously been explored.MethodsA questionnaire asking how DNACPR decisions are made, communicated and perceived in their country was composed: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had 4 weeks to answer the questionnaire.Results78 responses (44%) were received from 43 countries. All continents were represented. 88% of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. 94% of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes towards death, medical education and culture, health economics and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions.ConclusionsThe majority of countries surveyed make some form of DNACPR decision but differing cultures and economic status contribute towards a heterogeneity of approaches to resuscitation decision-making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision-making and implementation.

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The POLST Paradigm and Form: Facts and Analysis

Cited by 17 publications

References 26 publications

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU*

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU*

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

Themes and variations: An exploratory international investigation into resuscitation decision-making

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