POLST and DNR: Misunderstandings That Confound Critical Care

Robert Glatter, MD; Ferdinando L. Mirarchi, DO


April 07, 2015

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Robert Glatter, MD: Good afternoon. My name is Dr Robert Glatter. I'm an attending physician at the Department of Emergency Medicine at Lenox Hill Hospital in New York City and also a member of the Medscape Emergency Medicine Editorial Board. I will be speaking today with Dr Ferdinando Mirarchi, who is Medical Director at the Department of Emergency Medicine at the University of Pittsburgh Medical Center Hamot in Eerie, Pennsylvania. He is also the principal investigator of The Realistic Interpretation of Advance Directives, or TRIAD (TRIAD I),[1] and later studies.

An advance directive (AD) form—a living will is the oldest type of AD[2]—often accompanies a patient who presents to the emergency department (ED) for emergent care. But despite evidence suggesting that misunderstandings can lead to inappropriate care, few studies until TRIAD have actually examined provider understanding of that document and its effects on patient care.

Dr Mirarchi has agreed to join us today to continue the discussion of his TRIAD research and to update us regarding implications for patient care of the just-released TRIAD VI[3] and TRIAD VII[4] studies, which evaluated understanding of these documents by emergency physicians and prehospital providers.

The early TRIAD studies were devised based on three findings about AD forms:

  1. They often lack individualization for the patient.

  2. They do not provide for informed consent on the part of the patient or dependent.

  3. They often are misinterpreted as "do not resuscitate" (DNR) or "do not treat"[5] types of orders.

It found that there is an overwhelming amount of confusion across the nation as far as what to do with these documents and when they come into play in the clinical scenario of the critically ill patient.

ADs, DNR, and POLST Forms

Dr Glatter: Early TRIAD research also revealed that providers equate a living will, or ADs, with a DNR order. A DNR is a medical order, but it also has a legal definition in state statutes. It comes into play only if the person has no pulse or is not breathing.

Of note, the TRIAD studies also revealed that there is an assumption that a DNR order equates with end-of-life care. There is much misinterpretation of that term, despite the fact that it has been around for more than 20 years.

Now, though, we have the Physician Orders for Life-Sustaining Treatment (POLST)[6] form, which provides greater insight and ability to plan for care of those who have serious illness or frailty and who are expected to live less than a year.

TRIAD III[7] looked at living wills in regard to residents, and also faculty, at accredited training centers and found that, in general, residents and attendings are not prepared to deal with the documents or orders and require education. TRIAD IV[8] demonstrated further that medical schools are not preparing their students to be able to deal with the documents and orders in critical care scenarios as they enter internship and residency.

I'd like to welcome Dr Mirarchi now and begin with a discussion of the TRIAD VI and VII studies. I do want to first, Dr Mirarchi, give you the opportunity to make some major points about your preceding work.

Ferdinando L. Mirarchi, MD: Thank you, Dr Glatter, and thank you, Medscape, for having me back. Just to recap, the last time we spoke, we talked primarily about TRIAD III and TRIAD IV.

TRIAD III[7] was our nationwide study that essentially looked at the amount of understanding of ADs or living wills by emergency medicine residents, internal medicine residents, family medicine residents, and attendings in those specialties. The study found that the overwhelming majority of those populations of medical practitioners viewed a living will as a DNR. That in itself raised issues. Then we found that the DNR was misunderstood as well.

When we looked at treatment, there was a lack of consensus about who should get defibrillated and who should get intubated for critical illness when the conditions were easily reversible and treatable.

That led us to talk about the creation of checklists, and pauses during which there could be discussions to try to individualize care. At the time when we talked about that, we did not yet have the results of TRIAD VI and VII.

Results from TRIAD VI and VII have now been published by the Journal of Patient Safety.[3,4] TRIAD VI is our assessment of emergency physicians' understanding of POLST in Pennsylvania. TRIAD VII is our prehospital medical workers' understanding of POLST in Pennsylvania. The results of the two studies actually are very similar, in that there is lots of confusion surrounding the POLST, as well as the other documents in the setting of critical illness.

Improving Understanding

Dr Glatter: What do you think is the main issue that contributes to the misunderstandings? Is it that we haven't been educated about how to decipher such documents?

Dr Mirarchi: If you look back to the Patient Self-Determination Act of 1990[9]—it went into effect in 1991[10]—one of the proposed failures was that we rolled out a process, but we failed to fund the education. We failed to set standards. We failed to set requirements, not just for initial education but for education on a continual basis, such as our continuing medical education or licensure requirements.

I think those were big failures early on. Now it looks like we're following that same path with POLST. As a nation, we're adopting the POLST process with very limited research and without setting specific standards or specifying education and training. We should have a curriculum of instruction for physicians, nurses, prehospital, and advanced practice providers. Many people touch a patient's chart and literally touch a patient, and they affect the delivery of care that affects life or death.

Dr Glatter: You hit on a point that strikes so true. We all need to check each other. In any kind of surgical procedure, there are checks and balances—nurses checking doctors and reconfirming, for example, the site of surgery. We all should reconfirm things among ourselves in order to enhance the patient care experience and to do the right thing.

Dr Mirarchi: That is especially so in the face of critical care, because death is different from critical illness. If you find someone dead, that's one thing. If you come across somebody who's critically ill, there could be time to affect the care and delivery of care.

What I'm recommending as far as checklists, from research, is really not much different from what is recommended by the National POLST Paradigm Task Force (NPPTF) in conjunction with the American Bar Association.[11,12] If you look at the second page of a POLST document,[13] it says to reconfirm the patient's decisions. But that's near the bottom of page two, unfortunately, and people don't read it.

Understanding the POLST Form

Dr Mirarchi: I'm just trying to bring awareness to the situation that POLST has a very specific, narrow indication for frail, elderly patients who are expected to die within 6 months to a year. It was never meant to be used for every patient who gets admitted to a hospital, or meant for an institution to use it to document code status in the files of all patients who get admitted to a hospital.

Dr Glatter: Exactly. Does the POLST document in any way equal informed consent, in that sense? How would you define the document?

Dr Mirarchi: No, and I think that really needs clarification. Right now, the POLST document does not equate with informed decision-making on the part of the patient. There may be even some question of whether it equates with informed decision-making on the part of a provider, because what has been published by the task force is essentially based on looking at their database—which is good research, but its database-driven research. It's a retrospective look at what medical providers enter into a database.

The form is not a patient's understanding. You're hopefully getting a medical provider's understanding. I say "hopefully," because a lot of these forms are completed by nonmedical personnel. Then they get signed by a physician. Whose understanding are we really capturing? That's something that should be questioned when you look at database research.

Dr Glatter: Right. That raises the issue of what patients can understand about these documents. Has there been any study that has evaluated the ability of patients or family members to understand and really make sense of the POLST form?

Dr Mirarchi: Not that I know of. We are trying to put a study like that in place right now—one of the TRIAD series. We want to understand how patients perceive this form. What I'm theorizing is that what we're projecting isn't matching up to or mirroring a patient's understanding.

Care for Critical Illness vs End-of-Life Care

Dr Glatter: There is an issue regarding the Institute of Medicine (IOM) and how resuscitation goes forward, survival rates, the cost of resuscitation, and the ethics behind the process.[14] In terms of a resuscitation pause and errors during the evaluation of this pause, has the IOM weighed in on this issue regarding POLST documents and such?

Dr Mirarchi: Interestingly, the IOM came out with a major report on end of life care.[15] It does show that our system for delivering that kind of care is broken. The IOM takes a look at things, but not so much from a safety perspective or even looking at error rates—in fact, I couldn't find anything except our earlier two TRIAD studies that are referenced in that report in regard to possible confusion and lack of understanding. Nowhere is there a standard in that document to try and define an expected error rate. In fact, I was rather shocked that the issue of patient safety was not looked at from an error rate perspective.

The IOM is ramping up to increase awareness and cognizance of medical errors in physicians and medical practices. Yet their report on end-of-life care does not even look at medical errors.

I want to go back for a second to emphasize that. It's not just end-of-life care that we're concerned with; it's critical illness, too. We have to look at things in two situations: one if a patient is in cardiac arrest, and the other if that patient is critically ill. The treatment choices might be completely different.

Do We Know the Patient's Wishes?

Dr Glatter: Yes, going forward with lifesaving resuscitation could mean a good quality of life for some patients. We don't have to just choose not to resuscitate. Certainly it depends on other considerations—comorbidities and patient selection.

Dr Mirarchi: Absolutely. I think that what this comes down to is individualizing care rather than "cookbooking" care. When we look at patients, we definitely don't want to treat someone who may be near the point of cardiac arrest in relation to an illness clearly specified in the POLST document. But we may want to rethink the process in other clinical scenarios. We would probably want to treat a 65-year old retiree who has a myocardial infarction (MI) and goes into ventricular fibrillation. We want to give that person an expected chance of survival.

People sometimes say to the medical profession, "You might be treating a patient outside of their wishes." I'm pretty sure, though, that when you tell a patient that delivering therapy within a specified period of time and ensuring good care creates the potential for survival and good quality of life, they would accept that. We don't know for sure the patient's answer to these questions. In fact, that's the most important thing that's missing here. We lack the patient's voice in this whole process because we're working off forms.

In fact, that's one of the other studies we're trying to accomplish right now—how to bring the patient's voice back into those documents and those forms. With the technology today, we should be able to do that.

POLST: The Need for Regulations

Dr Glatter: I think you bring up a good point. If patients knew the positive possibilities in certain situations, I think they would potentially choose other options than those documented originally in their directives.

Dr Mirarchi: To expand on one point in POLST, I want people to realize and the profession to realize—and even the POLST group to realize—that this is not about POLST. POLST is a form and a process. It has a specified indication. When you take that specified indication and launch it across the country, trying to encompass 300 million people, you're going to have issues when there are no supporting standards and regulations.

When you look at POLST right now, there is no regulation or oversight of the whole process. Think about it. When I write for an aspirin for a cardiac patient experiencing an MI, I have to jump through six or seven different hoops. In addition, there's nursing read-backs and pharmacist oversight, not to mention real-time interaction checkers in the system.

For me to write a DNR order, for the most part, I just have to find the form. It's one step. People are then overly willing then to enact that form on an individual patient. They are overly willing to withhold care and treatment. This is an area that we really need to look back on, to investigate, and to set some standards. We have to establish error rates, and bring about standards to the practice.

Dr Glatter: Would the Joint Commission, which accredits and certifies so many healthcare organization and programs in the United States, be the organization to enforce this somehow, or would you say it would be done at a higher level than that?

Dr Mirarchi: I would hope the Joint Commission, the American College of Cardiology, the American Heart Association, and the Chest Pain Center Accreditation systems would take notice of this. The Joint Commission's Patient Safety Advisory Group[16] recognizes that this is a real, valid patient safety risk. However, creating some sort of Joint Commission measure or requirement would take a long time. We're probably years away from that. It's my hope that at some time there will be a regulatory body overseeing the whole process.

Dr Glatter: Sounds like a good plan. I would like to thank you so much for your time, Dr Mirarchi. It's been a pleasure discussing your TRIAD study.

Dr Mirarchi: Thank you, Dr Glatter.


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