Executive Summary
A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment (POLST) forms, and that this likely leads to patients either receiving or not receiving treatment contrary to their wishes. Investigators suggest more training on these issues is needed, and recommend that clinicians take the time to clarify choices during periods of critical illness.
• A new study found that when presented with a range of clinical scenarios coupled with POLST forms reflecting patient wishes, emergency providers did not often reach a consensus on what actions they would take.
• Researchers say that “do not resuscitate” orders are commonly misinterpreted to mean do not treat, and there are also practice and regional variations in how end-of-life-care documents are interpreted.
• While a national organization establishes POLST recommendations and sample policies, the documents themselves are established and regulated at the state level, along with training procedures.
• Experts recommend that hospitals establish quality control procedures to ensure that end-of-life-care documents are prepared and interpreted accurately.
Experts say more training, awareness needed to clear up confusion
A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment (POLST) forms, and that this likely leads to patients either receiving or not receiving treatment contrary to their wishes. Investigators suggest more training on these issues is needed, and recommend that clinicians take the time to clarify choices during periods of critical illness.
A new study found that when presented with a range of clinical scenarios coupled with POLST forms reflecting patient wishes, emergency providers did not often reach a consensus on what actions they would take.
Researchers say that “do not resuscitate” orders are commonly misinterpreted to mean do not treat, and there are also practice and regional variations in how end-of-life-care documents are interpreted.
While a national organization establishes POLST recommendations and sample policies, the documents themselves are established and regulated at the state level, along with training procedures.
Experts recommend that hospitals establish quality control procedures to ensure that end-of-life care documents are prepared and interpreted accurately.
There is new evidence that both emergency physicians and prehospital providers struggle, at times, to correctly interpret end-of-life-care instructions spelled out in POLST documents. In a study led by Ferdinando Mirarchi, DO, FAAEM, FACEP, medical director of the Department of Emergency Medicine at the University of Pittsburgh Medical Center (UPMC) Hamot in Erie, PA, investigators discovered that many care providers find the POLST forms confusing; as a result, the care choices indicated in the POLST forms are likely not always carried out in the way patients intended.1
To conduct the research, Mirarchi and colleagues surveyed members of the Pennsylvania chapter of the American College of Emergency Physicians (ACEP) to gauge their understanding of the POLST documents. In the survey, both physicians (223) and prehospital providers (1,069) were presented with various clinical scenarios involving critically ill patients along with POLST forms indicating the patients’ choices regarding resuscitation and treatment. Participants were then asked to state how they would respond in each clinical scenario.
Investigators evaluated rates of consensus, which they defined as 95% agreement, in each clinical scenario, and found that there were many instances in which the participant responses indicated a much lower level of agreement on what the various POLST instructions meant. In fact, in a majority of the clinical scenarios presented, the responses by both the physicians and the prehospital providers did not reach consensus levels.
Recognize variations in practice, understanding
For instance, when POLST forms specified DNR (do not resuscitate) with comfort measures only, 10% of physicians and 15% of prehospital providers indicated that they would still perform cardiopulmonary resuscitation (CPR). Mirarchi explains that some of this disagreement likely comes from a common but misapplied interpretation of what DNR means. “‘Do not resuscitate’ orders are equated with ‘do not treat’ orders or assumptions, ‘do not operate’ orders or assumptions, or end-of-life-care treatment,” he says. “That has been a known misunderstanding for many years now.”
There may also be regional or practice-level variations in what DNR orders are meant to convey, and just a general lack of education or training on when and how DNR orders should come into play, observes Mirarchi. “Take, for example, someone who is 60 years old and has a heart attack. At that point in time, it is a very treatable process,” he explains. “Now, if the patient goes into sudden cardiac arrest, that is another reversible, treatable process, especially if it is witnessed, so that is a person who would very rarely give consent to not having their treatment.”
However, when living wills or POLST documents are introduced into these types of scenarios, there is a high likelihood that patients will not receive the care and treatment that they would be expected to receive, explains Mirarchi. “Most of these documents have different connotations. A living will is not a DNR order. Those documents can exist together. A living will can exist with a DNR order but, by and large, a living will is not a DNR order,” he says.
On the other hand, a POLST form can be a DNR order because of the way it is structured and formatted, and this is where a lot of the confusion comes in, notes Mirarchi. “What people think they put into a form may not have the desired effect. It may have a completely opposite effect, depending on the understanding of the person reading the form, if, in fact, they have actually read the form,” he says. “Oftentimes, we find out that people don’t read the forms. They think they have an understanding of what the form is, and then they act or don’t act depending on what their perceived understanding of what the form is.”
For example, Mirarchi recalls the case of a 67-year-old man who had a living will. “When he met with his attorney, [the lawyer] essentially said the document would only come into play when there is nothing else [clinicians] can do for him in medicine,” he says. However, when the man suffered a myocardial infarction (MI), it almost went untreated because of someone’s misunderstanding of the living will document, adds Mirarchi.
In these types of circumstances, clinicians may equate having a living will with a patient not wanting life-saving care, even in cases in which the patient has a very treatable condition, explains Mirarchi. Clinicians may feel as though they are following the patient’s wishes when that is not the wish of the patient at all, he says.
Take steps to verify choices
To prevent such misunderstandings from leading to unwanted or tragic results, Mirarchi created a checklist that emergency clinicians can use whenever POLST or other end-of-life care documents are introduced in the midst of a resuscitative scenario. “Most people think of resuscitation as [involving] just cardiac arrest patients, but that is not the case anymore,” says Mirarchi, noting that things like sepsis, stroke, and trauma all have processes and activation teams that come in and immediately resuscitate patients. “When you introduce these documents into those scenarios, that is when people are at risk to either be over-treated or under-treated because of provider misunderstanding of those [end-of-life care] documents.”
The checklist, which clinicians can remember by the letters A, B, C, D & E, involves:
• Asking patients or their surrogates to be clear about their intentions with respect DNR orders, POLST, or other living will documents;
• Being clear as to whether the patient has a terminal condition or a critical illness that can be treated;
• Communicating whether you think the condition is reversible with a good or poor prognostic outcome;
• Designing a plan of care and discussing the next steps;
• Explaining that it is OK to withhold treatment or to withdraw care if that is consistent with the patient’s wishes, and what the benefits are of palliative care and hospice are.
Mirarchi says that he is now accustomed to running through the early part of the checklist quickly to determine whether or not he needs to treat a patient, and he trains residents and attending staff to incorporate the process into their decision-making capacity as well. “Very rarely anymore do we have an instance where someone is under-resuscitated or over-resuscitated,” he says.
One of the issues with advance directives is that people tend to ignore them, but Mirarchi notes that often they are not ignored; it is just that they have not been activated yet. “They have not been triggered yet because we don’t [have all the information] at that point in time,” he says. “In that instance, you institute care and treatment and you essentially start to de-escalate when you get more information, and then make things more appropriate for the patient and their family.”
However, Mirarchi notes that the study makes clear that much more needs to be done to improve awareness, education, and training in how end-of-life care forms should be used and interpreted. “By far, it shows that there is still a lot of confusion with these documents in the setting of critical illness,” he says. “And the treatments that are provided often lack consensus for some of the most commonly treated critical illnesses that we see everyday in the ED.”
Consider national standards, recommendations
Bringing widely recognized standards to the way POLST documents are structured and used is complicated by the fact that every state makes its own policies, procedures, and rules. For example, while most states require POLST forms to be signed by a physician, that is not true in every case. Further, the forms vary from state to state and, in some cases, the content of the forms is dictated, at least in part, by legislative statute.
Despite these state-level variations, the National POLST Paradigm, based in Portland, OR, provides guidance and an endorsement process aimed at getting the states to use POLST documents in a consistent and effective way. “We encourage the states to contact us the minute they are thinking about establishing a POLST program,” explains Amy Vandenbroucke, JD, the executive director of the National POLST Paradigm. “We have a developing state assistance committee, and that committee is a group of people that [come from] states that have been endorsed and are very familiar with the tenets of the POLST program and what it takes to be endorsed, so we work with states to try to get them to reach that endorsement level.”
What endorsement means is that a state’s POLST program has been implemented in a form that complies with requirements that have been established by the national POLST paradigm task force, explains Vandenbroucke. For example, she notes that POLST programs should only be reaching out to patients who are ill or frail and someone their health care professional would not be surprised if was dead within a year. It is also important to insure that POLST forms are always voluntary, and that states have the right people at the table when they are devising their programs, adds Vandenbroucke.
Currently, a POLST program is in some level of development in 48 states, with 17 state programs having achieved endorsement level, says Vandenbroucke. “Endorsement doesn’t mean a program is at a statewide level. It just means that the state is working toward a statewide program,” she says. “It means that we are concurring that the [POLST] form and the program are meeting our standards.”
Similarly, while the national organization does not offer training to clinicians or others involved with preparing POLST documents with patients, it does facilitate connections to resources. “For example, California has a very good train-the-trainer program. The state has done a good job implementing it, and they have really good materials,” says Vandenbroucke. “So if states are looking to do something, and they talk to me, I might connect them to the California program.”
Vandenbroucke notes that both Hawaii and Maine have taken the California program materials and are adapting them for their own states. “States don’t need to reinvent the wheel, but the national office has not independently created those kinds of educational materials just yet,” explains Vandenbroucke.
Establish quality control procedures
Judy Thomas, JD, the chief executive officer of the Coalition for Compassionate Care of California (CCC) in Sacramento, CA, explains that the group developed a two-day training program on how to have a POLST conversation. “The form is only as good as the conversation,” she says. “The form just documents the conversation.”
Since CCC cannot go to every community, it has trained more than 900 people on how to train others to conduct the POLST conversation. “We have 25 local coalitions around California that work at the local level,” says Thomas. Further, when problems with the process or the form crop up, these local coalitions serve as CCC’s eyes and ears. “When they need clarity from the state, they let us know,” she says.
The group has developed model policies and procedures for hospitals, nursing homes, and hospices, and it has developed brochures about POLST for both consumers and providers. However, she notes that the types of issues referenced by Mirarchi are not necessarily a problem with the POLST process but rather a sign that clinicians may not be in agreement on many of these issues. In particular, clinicians outside the ED, who work more frequently with patients having terminal illnesses, are in need of education and clarity.
“We heard that before POLST, people thought that DNR meant don’t do anything, so that is one of the reasons why we like POLST, because it doesn’t just talk about DNR, it also talks about other medical interventions to give a somewhat more nuanced understanding of a patient’s wishes,” says Thomas. “Also, in California, we felt that if someone does want resuscitation attempted, then they are basically buying into the whole process, which could mean intubation in the ICU ... so people need to understand that the instructions on attempted resuscitation can lead to that.”
Not every state has agreed with this interpretation, so there is a lack of consensus in the larger clinical community. And Thomas acknowledges that the process of educating hundreds of thousands of physicians and nurses in all of the hospitals and nursing homes in California is challenging.
What can hospitals do to insure that staff are interpreting and using POLST forms correctly? Thomas recommends that administrators develop quality-control procedures, including a chart audit process to insure that the forms are being filled out completely and accurately. She also suggests that clinical leaders regularly include cases involving end-of-life care instructions when they make grand rounds. “There are opportunities to identify real situations involving POLST forms that either went well or could have gone better,” she says. “Use them as a training opportunity.”
In California, a physician leadership council for POLST is set up as a mechanism for physicians to have regular input on the POLST process. “Each of our local coalitions need to have a physician champion or leader because this is a physician forum,” says Thomas. “We have about 25 physicians who meet via conference call every month and they talk about all sorts of issues.”
Consequently, when problems or issues are identified at the state level, they go to this group for consideration, says Thomas. “If there is some confusion, or we need clarity, we can get guidance,” she says.
Editor’s note: For more information or resources regarding POLST implementation, visit the website for the National POLST Paradigm at www.polst.org.
REFERENCE
- Mirarchi F, Doshi A, Zerkle S, Cooney T. TRIAD VI. How well do emergency physicians understand physicians orders for life sustaining treatment (POLST) forms? J Patient Safety 2015; 11:1-8.
SOURCES
- Ferdinando Mirarchi, DO, FAAEM, FACEP, Medical Director, Department of Emergency Medicine, University of Pittsburgh Medical Center Hamot, Erie, PA. E-mail: [email protected].
- Judy Thomas, JD, Chief Executive Officer, Coalition for Compassionate Care of California, Sacramento, CA. E-mail: [email protected].
- Amy Vandenbroucke, JD, Executive Director, National POLST Paradigm, Portland, OR. E-mail: [email protected].
A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment forms, and that this likely leads to patients either receiving or not receiving treatment contrary to their wishes.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content
Already have an account? Log in