The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department

Abbott, Jean

doi:10.1016/j.annemergmed.2018.10.021

Cited by 10 publications

(16 citation statements)

References 31 publications

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“…More than half of elderly patients will visit an emergency department in the last month of life. 8,22 Moreover, 50% will not be able to participate in the decision-making process when at EOL. 2,8 However, when the patient enters a healthcare facility, they are often asked two questions: “Do you have a living will?” and “How do you want to be treated if you experience cardiac arrest?” Answers to these questions get documented in the form of code status for resuscitation and go unchecked as far as quality oversight.…”

Section: Discussionmentioning

confidence: 99%

“…8,22 Moreover, 50% will not be able to participate in the decision-making process when at EOL. 2,8 However, when the patient enters a healthcare facility, they are often asked two questions: “Do you have a living will?” and “How do you want to be treated if you experience cardiac arrest?” Answers to these questions get documented in the form of code status for resuscitation and go unchecked as far as quality oversight. In the present study, we found significant amounts of discordance between what was documented in the medical records and what the patients understood and agreed to, with an approximate discordance rate of 30% to 40%.…”

Section: Discussionmentioning

confidence: 99%

“…This led to the creation of the National POLST Paradigm, which is now approved or operationalized very quickly in some form in all 50 states. 8 Of concern, the Oregon POLST process, which began the National POLST, has now withdrawn from the National POLST Paradigm in 2017, citing concerns of conflicts of interest, and now operates as the Oregon POLST. 8,9 The acronym used by states participating in the National POLST can vary (MOST, MOLST, POLST) as can the content, color, and format of the forms.…”

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confidence: 99%

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TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records

et al. 2019

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This study contributes to the current body of research in this area by examining the most current data, a more robust sample, and a methodology that allows analysis of actual rather than extrapolated last-year-of-life expenses. The analysis has shown current trends in decedent/survivor costs, their relationship to each other, and the changes in this relationship over time. In addition, the finding that the relationship has changed to varying degrees by age groups provides the impetus for including age, gender, and decedent/survivor refinements into the current Medicare projection methodology.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records

et al. 2019

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“…[13] Recent evidence indicates that half of the elderly patients visited the emergency room in the last month of their lives. [14] Chan [15] reported that patients came to EDs with unexpected injuries, chronic disease exacerbations, or perhaps terminal illnesses seeking lifesaving or life-prolonging treatment. Aggressive invasive treatment and life-prolonging strategies are usually prioritized due to complications and rapid changes in patients' conditions.…”

Section: Introductionmentioning

confidence: 99%

“…[19,20] The medical staff often have little information about patients' wishes and have no previous relationship with them. [14] Several studies on DNR in the acute care setting have been reported in intensive care units (ICUs). To our knowledge, this remains the first pilot study on the implementation of DNR directives to patients at their end-of-life in EDs in the Chinese mainland.…”

Section: Introductionmentioning

confidence: 99%

Death and do-not-resuscitate order in the emergency department: A three-year retrospective study in the Chinese mainland

et al. 2020

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BACKGROUND: Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS: This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS: There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors infl uenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confi dence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS: In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.

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TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end‐of‐life—The Realistic Interpretation of Advance Directives

Mirarchi

Juhasz

Cooney

et al. 2020

J of Healthc Risk Manag

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Objective Utilize simulation to evaluate if living wills (LW) or POLST achieves goal concordant Care (GCC) in a medical crisis. Methods Nurses and resident‐physicians from a single center were randomized to a clinical scenario with a living will (LW), physician orders for life sustaining treatment (POLST) or no document. Primary outcomes were resuscitation decision and time to decision. Secondary outcome was the effect of education. Results Total enrollment was 57 and less than 30% received prior training. Types of directives were linked to resuscitation decisions (P = .019). Participants randomized to “No Document” or POLST specifying “CPR” performed resuscitation. If a terminal condition presented with a POLST/ do not resuscitate‐comfort measures only (DNR‐CMO), 73% resuscitated. The LW or POLST specifying DNR combined with medical support resulted in resuscitations in 29% or more of the scenarios. Documents did not significantly affect median time‐to‐decision (P = .402) but decisions for “No Document” and POLST/CPR were at least 10 s less than other scenarios. Scenarios involving POLST DNR/Limited Treatment had the highest median time of 43 s. Prior training in LWs and POLST exerted a 10% improvement in decision making (P = .537). Conclusion GCC was not always achieved with a LW or POLST. This conclusion supports prior research identifying problems with the interpretation and discordance with LW's and POLST.

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The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department

Cited by 10 publications

References 31 publications

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records

Death and do-not-resuscitate order in the emergency department: A three-year retrospective study in the Chinese mainland

TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end‐of‐life—The Realistic Interpretation of Advance Directives

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