Incomplete End-of-Life Forms Vex Physicians

Troy Brown, RN

October 14, 2016

A study of elderly patients' end-of-life forms found that 69% had at least one section left blank, and 14% indicated the patient wanted comfort measures only, but also that they wanted be sent to the hospital, receive intravenous fluids, and/or receive antibiotics. These inconsistencies would likely result in patients receiving unwanted emergency care.

"Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the [Medical Orders for Life-Sustaining Treatment (MOLST)] form is sufficient for directing their end of life care," the authors write. "However, the result of making some, but not all choices, may result in patients receiving undesired, extraordinary, or invasive care. Educating providers, patient[s], and proxies on the implications of decision by default is essential."

Brian Clemency, DO, associate professor of emergency medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo School of Medicine, New York, and colleagues report their findings in an article published online September 30 in the Journal of the American Medical Directors Association.

Such forms are referred to by several names and are commonly called Physicians' Orders for Life-Sustaining Treatment (POLST) forms, but were referred to as MOLST at the study site. POLST forms are an important way for patients to ensure they receive medical care in accordance with their wishes if they become incapacitated and unable to directly communicate their wishes to healthcare providers. But healthcare providers are often confused about what the patient wants because the forms are completed incorrectly.

"We want to do what the patient wants, but if you don't tell us what you want, we're forced to assume you want 'everything' done," Dr Clemency explained in a University at Buffalo news release.

The researchers analyzed 100 MOLST forms that accompanied patients (64% female; median age, 79 years) to the emergency department of a large hospital. The forms addressed patients' wishes regarding life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids, and wishes for future hospitalization or transfer. The investigators developed an a priori list of combinations of medical orders that were contradictory, such as wanting cardiopulmonary resuscitation but not intubation.

According to that a priori list, the authors found that many of the forms had inconsistencies between sections, including the inconsistencies regarding the desire for comfort measures only mentioned earlier. In addition, whereas 78% of patients indicated they wanted no resuscitation, many either provided no further guidance on treatment limitations or requested incongruous care, such as no limitations on medical interventions, intubation, and long-term mechanical ventilation, antibiotics, or a trial period of a feeding tube. Similarly, on 22% of forms, patients said they wanted cardiopulmonary resuscitation but did not want measures including intravenous fluids or intubation, or wanted limited interventions.

It is likely that patients and their families do not understand the meaning of some of the interventions needed, and these misunderstandings can be amplified when patients have more than one family member attempting to make decisions about a patient's care together.

"Interprofessional education regarding end-of-life care may strengthen interdisciplinary teams and may help resolve such conflicts and produce POLST forms that more accurately reflect the patient's wishes and resolve contradictory directives," the authors explain. "Regardless of who initially prepares the POLST forms, it is important that signing physicians review the patient's wishes with the patient (or surrogate), to ensure that any inconsistencies or incomplete information is addressed when possible."

The authors have disclosed no relevant financial relationships.

J Am Med Dir Assoc. Published online September 30, 2016. Abstract

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