Some Providers Overlook POLSTs for End-of-Life Care

Close to 40% of patients in a recent study received end-of-life services in an intensive care unit, contrary to their wishes as documented in Physician Orders for Life-Sustaining Treatment (POLST).

Researchers considered 1,818 patients suffering from serious or chronic illness who died between 2010 and 2017 in a two-hospital academic health system. Some patients were hospitalized for as long as six months prior to death. Many of these patients would have qualified for hospice.

“Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLST,” the researchers found. “However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.”

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A key component of advance care plans, POLST forms document patient wishes and goals for end-of-life care, as well as namie a proxy to make decisions on behalf of the patient should they become unresponsive.

POLSTS that limit treatment at the end of life correlate with fewer deaths in a hospital, reduced unwanted CPR, as well as reduced overall hospitalizations. POLSTs have also been found to lower the intensive care unit utilization among residents of nursing homes.

Among the study’s 1,818 decedents, 401 had POLSTs indicating they preferred comfort measures only, while 761 had orders for limited additional interventions. The remaining 656 requested full treatment. The patients’ POLSTs were documented in their electronic health records.

Patients considered in the study suffered from one or more of nine conditions that account for 90% of deaths among Medicare beneficiaries, according to the study, which was published in the Journal of the American Medical Association. These include cancers with poor prognosis, chronic lung disease, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic renal failure, severe chronic liver disease, diabetes with end-organ damage, and dementia. Researchers did not include patients younger than 18 years at death as well as those hospitalized for elective surgery.

“The experiences of ICU patients and survivors suggest that patients receiving aggressive life-sustaining treatments experience a high burden of unrelieved physical symptoms and emotional distress. Additionally, intensive care and mechanical ventilation account for a disproportionate amount of health care expenditures within the last years of life,” the researchers wrote. “For patients who do not want aggressive treatments near the end of life, unwanted intensive care may incur physical, emotional, and financial costs while providing little value. Reducing unwanted intensive care near the end of life represents an opportunity to simultaneously improve patient-centered care and reduce costs.”