How well do POLST forms assure that patients get the end-of-life care they requested?
EVIDENCE-BASED ANSWER:
Quite well, for cardiopulmonary resuscitation (CPR). Most patients (91%-100%) who select “do not resuscitate” (DNR) on their physician’s orders for life-sustaining treatment (POLST) forms are allowed a natural death without attempted CPR across a variety of settings (community, skilled nursing facilities, emergency medical services, and hospice). Few patients (6%) who select “comfort measures only” die in the hospital, whereas more (22%) who choose “limited interventions,” and still more (34%) without a POLST form, die in the hospital (strength of recommendation [SOR]: B, large, consistent cross-sectional and cohort studies).
Most patients (84%) who select “attempt resuscitation” receive resuscitation for out-of-hospital cardiac arrest in emergency services settings (SOR: B, small retrospective cohort study).
POLST orders declining other services (intravenous fluids, intensive care, intubation, feeding tubes) are carried out in most (84%-100%) cases. POLST orders regarding antibiotic treatments are less effectively implemented (SOR: B, moderate-sized retrospective chart review).
Skilled nursing facilities: Generally high adherence to POLST orders
The largest study to evaluate the consistency of treatments with POLST orders among nursing home residents found high adherence overall (94%).5 Caregivers performed CPR on none of 299 residents who selected “DNR.” However, they did not administer CPR to 6 of 7 who chose “attempt CPR” and administered antibiotics to 32% of patients who specified “no antibiotics” on their POLST forms.5
A second study of nursing home residents who selected “comfort measures only” also found high consistency for attempting CPR, intensive care admission, and ventilator support, although physicians hospitalized 2% of patients to extend life.6 Similarly, treatments matched POLST orders well overall in a Washington state study, although one patient got a feeding tube against orders.7
POLST adherence is good, but can EMS workers find the form?
A study comparing emergency medical services (EMS) management with POLST orders in an Oregon registry found good consistency.8 EMS providers didn’t attempt or halted CPR in most patients with DNR orders who were found in cardiac arrest and initiated CPR in most patients who chose “attempt CPR.” EMS providers initiated CPR in the field on 11 patients (22%) with a DNR order but discontinued resuscitation en route to the hospital.
In a smaller study, EMS providers never located paper POLST forms at the scene in most cases.9
Hospice: POLST orders prevent unwanted Tx, except maybe antibiotics
A study evaluating management in hospice programs in 3 states found that care providers followed POLST orders for limited treatment in 98% of cases.10 No patients received unwanted CPR, intubation, or feeding tubes. POLST orders didn’t predict whether patients were treated with antibiotics, however.
