End-of-Life Wishes May Not Be Honored in the Hospital

By Megan Brooks

February 21, 2020

NEW YORK (Reuters Health) - Patients with documented treatment-limiting medical orders who are hospitalized near the end of life often receive care that is inconsistent with their preferences, according to a new study.

Physician Orders for Life-Sustaining Treatment (POLST) are portable medical orders that document treatment limitations for out-of-hospital emergency care and for limiting overtreatment at the end of life.

"We already know that POLST forms can help chronically ill patients avoid unwanted hospitalizations and CPR. However, we don't know very much about what happens when patients with POLST forms are admitted to the hospital near the end of life," Dr. Robert Y. Lee of Cambia Palliative Care Center of Excellence at the University of Washington School of Medicine, in Seattle, told Reuters Health by email.

To investigate, the researchers took a look back at 1,818 adults with completed POLST forms and chronic, life-limiting illnesses who were hospitalized six months or less before death. Of these, 36% had POLST orders for "full treatment" and 42% for "limited additional interventions" and 22% for "comfort measures only."

Among the combined latter two groups, 41% were admitted to the intensive-care unit (ICU), 38% received POLST-discordant intensive care, and 18% received POLST-discordant life-sustaining treatments (mechanical ventilation, vasoactive infusions, new renal replacement therapy, or CPR).

Patients with cancer or dementia were less apt to receive POLST-discordant intensive care, whereas patients hospitalized for traumatic injuries were more likely to receive POLST-discordant intensive care.

The findings were published online in JAMA to coincide with a presentation February 16 at the Society of Critical Care Medicine's 49th Critical Care Congress in Orlando, Florida.

"Our study showed that hospitalized patients who had selected limited or comfort-only care on their POLST forms were less likely to receive intensive care than patients who had selected full-treatment on their POLST forms," Dr. Lee told Reuters Health by email.

"In other words, what patients put on their POLST forms matters. Patients whose POLSTs say, 'avoid intensive care' are indeed less likely to receive intensive care. Our findings suggest that POLSTs can help hospitalized patients with chronic illness avoid unwanted intensive care," he noted.

On the flip side, however, the study also found that about one-third of hospitalized patients with POLST orders for limited care nevertheless were admitted to the ICU near the end of life, despite POLST orders that would ordinarily preclude ICU admission.

"This isn't necessarily always inappropriate, as unanticipated circumstances can arise that lead patients and families to change their minds about the types of care they would like to receive," Dr. Lee said.

"Nevertheless, we believe this suggests that there is room for improvement in how we implement POLSTs - specifically, in who we choose to recommend and complete POLST forms for, in how we communicate POLST orders across the continuum of healthcare, and in how we equip patients, families, and healthcare providers to make the healthcare decisions that are most true to the patient's wishes during moments of crisis," Dr. Lee added.

In a JAMA editorial, Dr. Robert Truog from Harvard Medical School, in Boston, and Dr. Terri Fried of Yale School of Medicine, in New Haven, Connecticut, say this study provides "important new information about the relationship between POLSTs and overtreatment of patients at the end of life" and the results are "sobering."

"These insights will assist clinicians in developing strategies to help ensure that patients hospitalized near the end of life receive only those treatments that are both desired and beneficial," they add.

SOURCE: http://bit.ly/2SE9UtW and http://bit.ly/2vL4HHo JAMA, online February 16, 2020.

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