- Email: [email protected]
Patients’ resuscitation preferences in context: Lessons from POLST
Resuscitation 85 (2014) 444–445
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Patients’ resuscitation preferences in context: Lessons from POLST
There have been recent initiatives in several countries1,2 to assist patients in considering what treatments they might or might not want and to ensure that these wishes are adequately communicated to health care providers across different health settings. In the USA, patients with terminal illnesses often receive intensive treatments, with 47% of hospital deaths occurring on Intensive Care Units, in contrast with only 10.1% in the UK.3 It is in this context that Physician Orders for Life Sustaining Treatments (POLST) were developed, initially in Oregon over a decade ago, but with continued iterative development across 26 states in the US. POLST forms are intended to be completed with a patient and their physician, ideally with their loved ones also involved. While Advance Decisions to Refuse Treatment and Advanced Directives generally refer to anticipated future treatments, POLST (see p. x) is intended only for those who already have ‘significant illness or frailty’.4 POLST allows people to discuss their wishes with their physician and document their treatment preferences concerning cardiopulmonary resuscitation, medical interventions (“comfort measures only, limited additional interventions or full treatment”) and artificially administered nutrition (“none, trial period or long term”). Community DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) forms predated POLST in the USA, but have only reached out of hospital environments in the UK and other countries recently. Designed to prevent patients with advanced or terminal illnesses receiving futile resuscitation attempts from paramedics who feel legally bound to do so, there is however evidence that community DNACPR forms may be misunderstood to indicate that other treatments should not be given, or that patients should not be admitted into hospital.5 This is consistent with literature concerning inpatient DNACPR forms in hospitals6 where patients receive fewer treatments than those without a DNACPR form.7–9 One of the strengths of POLST is that it provides clarity about resuscitation preferences within the context of which treatments, including hospitalization, are desired. Previous studies have assessed the implementation of POLST across a range of different care settings including hospices,10 hospitals,11 nursing homes,12,13 and throughout communities.14 Retrospective case note reviews15–17 and interviews of emergency medical technicians18 and clinicians12 have been conducted. These studies have all shown that POLST forms are honoured, with patients rarely receiving treatments that they did not want. When compared with DNACPR forms, patients with POLST forms were significantly more likely to have orders about life sustaining treatment preferences beyond resuscitation than those without them.19 In this issue of Resuscitation,4 Schmidt et al. present the first population based study of the embedded use of POLST across 0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2014.01.016
different case settings. Using the Oregon Electronic Registry, they analyzed a year’s entries (31,294 forms), investigating their use and the combinations of treatments that were chosen. These choices raise important questions about the decision-making processes, information sharing, and the physician-patient interactions involved in completion of POLST forms. The most common choices were intuitively logical. The most common was “no resuscitation and comfort measures only” (34.4%), where the patient would only be taken into hospital if their comfort needs could not be met at home. The second was “no resuscitation but limited additional interventions” (29.7%), where antibiotics and IV fluids may be used, but ITU or intubation generally avoided. The third most popular combination was “full treatment and attempted CPR” (23.9%), with patient preference for no ceiling of care. It is striking that so many patients chose to have official documentation to state their preference for this default option of CPR and active treatment. The remaining choices and their frequency deserve more detailed examination. It was concerning that a small but significant group of patients (7.3%) wanted “attempted resuscitation but only limited interventions”. While Ventricular Fibrillation might respond to a single shock, other forms of arrest are more common in this group of patients with “significant illness or frailty”. Full CPR attempts are unlikely to be successful without intubation or potential transfer to ICU that ‘limited interventions’ exclude: this combination could lead to significant confusion amongst health care professionals looking after the patient in a crisis. It was surprising was that very few patients wanted “full treatment but no resuscitation” (3.9%), a combination that would be valid for patients who wanted full active treatment – perhaps including ICU – for a reversible condition such as severe pneumonia, but who would not want CPR and its potential complications should they have a cardiopulmonary arrest. Given the frequency of the counterintuitive “attempted resuscitation but only limited interventions”, and the relative scarcity of the clinically sensible “full treatment but no resuscitation” the question arises how these decisions were made. Some information may be available from the Oregon Electronic Registry to augment the data presented in the paper. What proportion of patients dying in Oregon have POLST forms in place? What were the proportions of settings in which the POLST forms were completed: hospices, nursing homes, hospitals and the community? Were certain combinations of choices more frequent in some settings than others? How frequently were POLST forms reviewed? Were POLST decisions revisited as patients moved between health care settings?
Editorial / Resuscitation 85 (2014) 444–445
This study is heartening in showing how a novel approach has been widely taken up, and is valuable in telling us the kind of treatments patients might want. Its other strength is in provoking further questions about how decision-making is approached in this context. To what extent did patients discuss their choices with doctors and family before completing a POLST? Were patients adequately informed concerning the choices and combinations of choices they were making? Who were the doctors discussing these decisions: a familiar family doctor or specialist, or an unfamiliar physician in an emergency situation? Were they completed in an in- or out-patient setting? Were doctors supporting patients to make decisions which would translate into interpretable orders? As we move towards empowering patients are to make choices about what care they would or would not want, it is vital to understand the benefits and potential adverse effects of doing so. Qualitative investigation of patients’ and doctors’ perceptions of discussions about POLST, and what they believe has been decided on completion of a form would be welcome, with observational and Conversational Analysis studies of the discussions held. When discussing treatment options at the end of life, it has been suggested that discussions should focus on ‘acceptable health states’ rather than specific treatments.20 POLST’s use of “comfort measures only” enables patients to understand what their goal of care is without going through each potential clinical intervention. Discussion and documentation of patients’ preferences for care at the end of life is laudable and needed. We just need to be sure that what is documented by clinical staff truly reflects what is wanted by patients. Conflict of interest statement ZF is funded by a Wellcome fellowship in Bioethics, and has conducted work on developing the Universal Form of Treatment Options (UFTO), an alternative to DNACPR orders. SB is funded by NIHR CLAHRC-East (Collaborations for Leadership in Applied Health Research and Care) and the Higher Education Funding Council for England. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR the Wellcome Trust or the Department of Health. References 1. Silvester W, Parslow RA, Lewis VJ, et al. Development and evaluation of an aged care specific Advance Care Plan. BMJ Support Palliat Care 2013;3: 188–95. 2. Fritz Z, Malyon A, Frankau JM, et al. The Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a mixed methods evaluation of the effects on clinical practice and patient care. PLoS ONE 2013;8:e70977. 3. Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med 2009;180:875–80. 4. Schmidt TA, Zive D, Fromme EK, Cook JN, Tolle SW. Physician Orders for LifeSustaining Treatment (POLST): lessons learned from analysis of the Oregon POLST Registry. Resuscitation 2014.
445
5. Zweig SC, Kruse RL, Binder EF, Szafara KL, Mehr DR. Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections. J Am Geriatr Soc 2004;52:51–8. 6. Fritz Z, Fuld J, Haydock S, Palmer C. Interpretation and intent: a study of the (mis)understanding of DNAR orders in a teaching hospital. Resuscitation 2010;81:1138–41. 7. Chen JL, Sosnov J, Lessard D, Goldberg RJ. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J 2008;156:78–84. 8. Cohen RI, Lisker GN, Eichorn A, Multz AS, Silver A. The impact of do-notresuscitate order on triage decisions to a medical intensive care unit. J Crit Care 2009;24:311–5. 9. Cohn S, Fritz ZB, Frankau JM, Laroche CM, Fuld JP. Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study. QJM 2013;106:165–77. 10. Hickman SE, Nelson CA, Moss AH, et al. Use of the Physician Orders for LifeSustaining Treatment (POLST) paradigm program in the hospice setting. J Palliat Med 2009;12:133–41. 11. Sugiyama T, Zingmond D, Lorenz KA, et al. Implementing physician orders for life-sustaining treatment in California hospitals: factors associated with adoption. J Am Geriatr Soc 2013;61:1337–44. 12. Caprio AJ, Rollins VP, Roberts E. Health care professionals’ perceptions and use of the medical orders for scope of treatment (MOST) form in North Carolina nursing homes. J Am Med Dir Assoc 2012;13:162–8. 13. Wenger NS, Citko J, O’Malley K, et al. Implementation of Physician Orders for Life Sustaining Treatment in nursing homes in California: evaluation of a novel statewide dissemination mechanism. J Gen Intern Med 2013;28:51–7. 14. Hammes BJ, Rooney BL, Gundrum JD, Hickman SE, Hager N. The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliat Med 2012;15:77–85. 15. Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc 1998;46:1097–102. 16. Lee MA, Brummel-Smith K, Meyer J, Drew N, London MR. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly. J Am Geriatr Soc 2000;48:1219–25. 17. Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc 2011;59:2091–9. 18. Schmidt TA, Hickman SE, Tolle SW, Brooks HS. The Physician Orders for Life-Sustaining Treatment program: Oregon emergency medical technicians’ practical experiences and attitudes. J Am Geriatr Soc 2004;52:1430–4. 19. Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc 2010;58:1241–8. 20. Rosenfeld KE, Wenger NS, Kagawa-Singer M. End-of-life decision making: a qualitative study of elderly individuals. J Gen Intern Med 2000;15:620–5.
Zoë B. McC. Fritz ∗ Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom Stephen I. Barclay (MA, FRCGP, MD) Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, United Kingdom ∗ Corresponding author. E-mail address: [email protected] (Z.B.McC. Fritz)
17 January 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Patients’ resuscitation preferences in context: Lessons from POLST
There have been recent initiatives in several countries1,2 to assist patients in considering what treatments they might or might not want and to ensure that these wishes are adequately communicated to health care providers across different health settings. In the USA, patients with terminal illnesses often receive intensive treatments, with 47% of hospital deaths occurring on Intensive Care Units, in contrast with only 10.1% in the UK.3 It is in this context that Physician Orders for Life Sustaining Treatments (POLST) were developed, initially in Oregon over a decade ago, but with continued iterative development across 26 states in the US. POLST forms are intended to be completed with a patient and their physician, ideally with their loved ones also involved. While Advance Decisions to Refuse Treatment and Advanced Directives generally refer to anticipated future treatments, POLST (see p. x) is intended only for those who already have ‘significant illness or frailty’.4 POLST allows people to discuss their wishes with their physician and document their treatment preferences concerning cardiopulmonary resuscitation, medical interventions (“comfort measures only, limited additional interventions or full treatment”) and artificially administered nutrition (“none, trial period or long term”). Community DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) forms predated POLST in the USA, but have only reached out of hospital environments in the UK and other countries recently. Designed to prevent patients with advanced or terminal illnesses receiving futile resuscitation attempts from paramedics who feel legally bound to do so, there is however evidence that community DNACPR forms may be misunderstood to indicate that other treatments should not be given, or that patients should not be admitted into hospital.5 This is consistent with literature concerning inpatient DNACPR forms in hospitals6 where patients receive fewer treatments than those without a DNACPR form.7–9 One of the strengths of POLST is that it provides clarity about resuscitation preferences within the context of which treatments, including hospitalization, are desired. Previous studies have assessed the implementation of POLST across a range of different care settings including hospices,10 hospitals,11 nursing homes,12,13 and throughout communities.14 Retrospective case note reviews15–17 and interviews of emergency medical technicians18 and clinicians12 have been conducted. These studies have all shown that POLST forms are honoured, with patients rarely receiving treatments that they did not want. When compared with DNACPR forms, patients with POLST forms were significantly more likely to have orders about life sustaining treatment preferences beyond resuscitation than those without them.19 In this issue of Resuscitation,4 Schmidt et al. present the first population based study of the embedded use of POLST across 0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2014.01.016
different case settings. Using the Oregon Electronic Registry, they analyzed a year’s entries (31,294 forms), investigating their use and the combinations of treatments that were chosen. These choices raise important questions about the decision-making processes, information sharing, and the physician-patient interactions involved in completion of POLST forms. The most common choices were intuitively logical. The most common was “no resuscitation and comfort measures only” (34.4%), where the patient would only be taken into hospital if their comfort needs could not be met at home. The second was “no resuscitation but limited additional interventions” (29.7%), where antibiotics and IV fluids may be used, but ITU or intubation generally avoided. The third most popular combination was “full treatment and attempted CPR” (23.9%), with patient preference for no ceiling of care. It is striking that so many patients chose to have official documentation to state their preference for this default option of CPR and active treatment. The remaining choices and their frequency deserve more detailed examination. It was concerning that a small but significant group of patients (7.3%) wanted “attempted resuscitation but only limited interventions”. While Ventricular Fibrillation might respond to a single shock, other forms of arrest are more common in this group of patients with “significant illness or frailty”. Full CPR attempts are unlikely to be successful without intubation or potential transfer to ICU that ‘limited interventions’ exclude: this combination could lead to significant confusion amongst health care professionals looking after the patient in a crisis. It was surprising was that very few patients wanted “full treatment but no resuscitation” (3.9%), a combination that would be valid for patients who wanted full active treatment – perhaps including ICU – for a reversible condition such as severe pneumonia, but who would not want CPR and its potential complications should they have a cardiopulmonary arrest. Given the frequency of the counterintuitive “attempted resuscitation but only limited interventions”, and the relative scarcity of the clinically sensible “full treatment but no resuscitation” the question arises how these decisions were made. Some information may be available from the Oregon Electronic Registry to augment the data presented in the paper. What proportion of patients dying in Oregon have POLST forms in place? What were the proportions of settings in which the POLST forms were completed: hospices, nursing homes, hospitals and the community? Were certain combinations of choices more frequent in some settings than others? How frequently were POLST forms reviewed? Were POLST decisions revisited as patients moved between health care settings?
Editorial / Resuscitation 85 (2014) 444–445
This study is heartening in showing how a novel approach has been widely taken up, and is valuable in telling us the kind of treatments patients might want. Its other strength is in provoking further questions about how decision-making is approached in this context. To what extent did patients discuss their choices with doctors and family before completing a POLST? Were patients adequately informed concerning the choices and combinations of choices they were making? Who were the doctors discussing these decisions: a familiar family doctor or specialist, or an unfamiliar physician in an emergency situation? Were they completed in an in- or out-patient setting? Were doctors supporting patients to make decisions which would translate into interpretable orders? As we move towards empowering patients are to make choices about what care they would or would not want, it is vital to understand the benefits and potential adverse effects of doing so. Qualitative investigation of patients’ and doctors’ perceptions of discussions about POLST, and what they believe has been decided on completion of a form would be welcome, with observational and Conversational Analysis studies of the discussions held. When discussing treatment options at the end of life, it has been suggested that discussions should focus on ‘acceptable health states’ rather than specific treatments.20 POLST’s use of “comfort measures only” enables patients to understand what their goal of care is without going through each potential clinical intervention. Discussion and documentation of patients’ preferences for care at the end of life is laudable and needed. We just need to be sure that what is documented by clinical staff truly reflects what is wanted by patients. Conflict of interest statement ZF is funded by a Wellcome fellowship in Bioethics, and has conducted work on developing the Universal Form of Treatment Options (UFTO), an alternative to DNACPR orders. SB is funded by NIHR CLAHRC-East (Collaborations for Leadership in Applied Health Research and Care) and the Higher Education Funding Council for England. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR the Wellcome Trust or the Department of Health. References 1. Silvester W, Parslow RA, Lewis VJ, et al. Development and evaluation of an aged care specific Advance Care Plan. BMJ Support Palliat Care 2013;3: 188–95. 2. Fritz Z, Malyon A, Frankau JM, et al. The Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a mixed methods evaluation of the effects on clinical practice and patient care. PLoS ONE 2013;8:e70977. 3. Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med 2009;180:875–80. 4. Schmidt TA, Zive D, Fromme EK, Cook JN, Tolle SW. Physician Orders for LifeSustaining Treatment (POLST): lessons learned from analysis of the Oregon POLST Registry. Resuscitation 2014.
445
5. Zweig SC, Kruse RL, Binder EF, Szafara KL, Mehr DR. Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections. J Am Geriatr Soc 2004;52:51–8. 6. Fritz Z, Fuld J, Haydock S, Palmer C. Interpretation and intent: a study of the (mis)understanding of DNAR orders in a teaching hospital. Resuscitation 2010;81:1138–41. 7. Chen JL, Sosnov J, Lessard D, Goldberg RJ. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J 2008;156:78–84. 8. Cohen RI, Lisker GN, Eichorn A, Multz AS, Silver A. The impact of do-notresuscitate order on triage decisions to a medical intensive care unit. J Crit Care 2009;24:311–5. 9. Cohn S, Fritz ZB, Frankau JM, Laroche CM, Fuld JP. Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study. QJM 2013;106:165–77. 10. Hickman SE, Nelson CA, Moss AH, et al. Use of the Physician Orders for LifeSustaining Treatment (POLST) paradigm program in the hospice setting. J Palliat Med 2009;12:133–41. 11. Sugiyama T, Zingmond D, Lorenz KA, et al. Implementing physician orders for life-sustaining treatment in California hospitals: factors associated with adoption. J Am Geriatr Soc 2013;61:1337–44. 12. Caprio AJ, Rollins VP, Roberts E. Health care professionals’ perceptions and use of the medical orders for scope of treatment (MOST) form in North Carolina nursing homes. J Am Med Dir Assoc 2012;13:162–8. 13. Wenger NS, Citko J, O’Malley K, et al. Implementation of Physician Orders for Life Sustaining Treatment in nursing homes in California: evaluation of a novel statewide dissemination mechanism. J Gen Intern Med 2013;28:51–7. 14. Hammes BJ, Rooney BL, Gundrum JD, Hickman SE, Hager N. The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliat Med 2012;15:77–85. 15. Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc 1998;46:1097–102. 16. Lee MA, Brummel-Smith K, Meyer J, Drew N, London MR. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly. J Am Geriatr Soc 2000;48:1219–25. 17. Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc 2011;59:2091–9. 18. Schmidt TA, Hickman SE, Tolle SW, Brooks HS. The Physician Orders for Life-Sustaining Treatment program: Oregon emergency medical technicians’ practical experiences and attitudes. J Am Geriatr Soc 2004;52:1430–4. 19. Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc 2010;58:1241–8. 20. Rosenfeld KE, Wenger NS, Kagawa-Singer M. End-of-life decision making: a qualitative study of elderly individuals. J Gen Intern Med 2000;15:620–5.
Zoë B. McC. Fritz ∗ Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom Stephen I. Barclay (MA, FRCGP, MD) Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, United Kingdom ∗ Corresponding author. E-mail address: [email protected] (Z.B.McC. Fritz)
17 January 2014