"Our data suggest that POLST orders can be confusing for Pennsylvania emergency physicians, and likely for physicians nationwide," write Dr. Ferdinando L. Mirarchi of UPMC Hamot, Erie, Pennsylvania, and co-authors. The POLST lets patients state their choices regarding resuscitation, either "do not resuscitate" (DNR) or full cardiopulmonary resuscitation (CPR); and other treatments, with options for full treatment, limited treatment, or "comfort measures" only.
Dr. Mirarchi and colleagues surveyed Pennsylvania emergency department physicians and prehospital care providers (paramedics and emergency medical technicians) regarding their understanding and interpretation of POLST forms. The POLST form is a one-page, brightly coloured document — varying in colour and formatting from state to state — that serves as an "active medical order" across healthcare settings.
Participants were presented with various clinical scenarios of critically ill patients, with POLST forms specifying different options for resuscitation and treatment. Rates of "consensus" (defined as 95 percent agreement) were assessed in the different situations. Surveys were completed by 223 emergency physicians and 1,069 prehospital care providers. The researchers found that:
- Even when the POLST specified "DNR" with "comfort measures" only, 10 percent of emergency physicians and 15 percent of prehospital providers indicated they would still perform CPR.
- The only situation to show 95 percent agreement was when the POLST form specified "CPR" and "full treatment."
- Older and more experienced physicians were less likely to choose "DNR" in certain situations. In both studies, responses were similar for participants with and without previous POLST training.
"Both studies reveal variable understandings and variable responses as far as treating critically ill patients with the available POLST combinations of choices," Dr. Mirarchi points out.
Intended to address the limitations of "living wills" and advance directives for end-of-life care, the POLST has quickly disseminated across the United States and has now been adopted by more than 20 states. The POLST is generally used by seriously ill patients for whom sudden death within the next year "would not be surprising." However, some states and institutions have adopted its use outside of the specified indications.
Previous reports have suggested that POLST orders can help to ensure that patients receive care consistent with their treatment goals. Moreover, POLST documents are very effective at limiting life-saving care and may prevent avoidable readmissions to hospitals.
However, there has been no study to confirm that the POLST combinations truly equate with informed consent by patients. Reports show that the majority of POLST forms are prepared by non-medical personnel, and then become actionable with a physician's signature.
"Our results reveal clinical and safety issues related to confusion" with POLST documents, Dr. Mirarchi and co-authors write. The research team calls for continued research, standards, and education to help ensure "patient autonomy and appropriate care" regarding life-sustaining treatments for people with serious illnesses and limited life expectancy.
Dr. Mirarchi's team has developed a patient safety checklist to be used at the time of resuscitation to remind providers to confirm and follow expressed treatment choices with an individualised plan of care for the patient.
Source: Wolters Kluwer Health
Image Credit: Nevada Rural Hospital Partners