Clinical Inquiries

How well do POLST forms assure that patients get the end-of-life care they requested?

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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).


 

References

EVIDENCE SUMMARY

The POLST form offers choices within 4 treatment areas: “attempt CPR” or “allow natural death” if the patient is in cardiopulmonary arrest; “comfort,” “limited,” or “full” medical interventions if pulse or breathing is present; choices of additional orders, including intravenous fluids, feeding tubes, and antibiotics; and additional written orders. Most POLST studies used cross-sectional and retrospective cohort designs and assessed whether CPR was attempted. Fewer studies also evaluated adherence to orders in the other treatment areas.

Community settings: Patients with POLST more likely to die out of hospital

The largest study of POLST use in community settings evaluated deaths in Oregon over one year.1 It found that patients who indicated “do not attempt CPR” on a POLST form were 6 times more likely to die a natural, out-of-hospital death than those who had no POLST form (TABLE1-10).

Are physicians' orders for life-sustaining treatments followed? The evidence for consistency image

A West Virginia study found that patients with POLST forms had 30% higher out-of-hospital death rates than those with traditional advanced directives and no POLST.2 In a Wisconsin study, no decedents who indicated DNR on their POLST forms received CPR.3

Are physicians' orders for life-sustaining treatments followed? The evidence for consistency image

One study that evaluated the consistency of actual medical interventions with POLST orders in all 4 treatment areas found it to be good in most areas (“feeding tubes,” “attempting CPR.” “antibiotics,” and “IV fluids”) except “additional written orders.4

Evidence-based answers from the Family Physicians Inquiries Network

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