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CME: POLST & Emergency Medicine: Considering the Issues

CME: POLST & Emergency Medicine: Considering the Issues
Author Information (click to view)

Arvind Venkat, MD

Vice Chair for Research and Faculty Academic Affairs
Department of Emergency Medicine
Allegheny Health Network
System Ethics Committee Chair
Allegheny Health Network
Ethics Consultant and Ethics Committee Chair
Allegheny General Hospital
Associate Professor of Emergency Medicine
Drexel University College of Medicine
Adjunct Associate Professor of Emergency Medicine
Temple University School of Medicine

Arvind Venkat, MD, has indicated to Physician’s Weekly that he has worked as a consultant for BluPanda, LLC and has received grants/research aid from Dyax, Novartis, the Romark Institute for Medical Research, Shire Human Genetic Therapies, and Ischemia Care, LLC, but notes that none of these are relevant to the article published in Physician’s Weekly.

Figure 2 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

  1. Explain the potential benefits of Physician Orders for Life-Sustaining Treatment (POLST) in addressing the challenges of providing end-of-life care in the emergency department;
  2. Discuss the needs for additional research focused on the use of POLST in the emergency setting.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwjune1.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria, Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Arvind Venkat, MD
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Arvind Venkat, MD (click to view)

Arvind Venkat, MD

Vice Chair for Research and Faculty Academic Affairs
Department of Emergency Medicine
Allegheny Health Network
System Ethics Committee Chair
Allegheny Health Network
Ethics Consultant and Ethics Committee Chair
Allegheny General Hospital
Associate Professor of Emergency Medicine
Drexel University College of Medicine
Adjunct Associate Professor of Emergency Medicine
Temple University School of Medicine

Arvind Venkat, MD, has indicated to Physician’s Weekly that he has worked as a consultant for BluPanda, LLC and has received grants/research aid from Dyax, Novartis, the Romark Institute for Medical Research, Shire Human Genetic Therapies, and Ischemia Care, LLC, but notes that none of these are relevant to the article published in Physician’s Weekly.

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Physician Orders for Life-Sustaining Treatment (POLST) is increasingly being used to communicate end-of-life care preferences for the seriously ill and frail. Although designed to be as clear as possible, there may be unexpected challenges in interpreting and using POLST in the ED.
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Emergency physicians frequently care for dying patients and are forced to make time-sensitive decisions without adequate medical history and knowledge of end-of-life care preferences. “Complicating these decisions is the fact that patients may be unable to communicate with their physicians,” says Arvind Venkat, MD. “In addition, accompanying documents—such as advance directives or do-not-resuscitate (DNR)/do-not-intubate (DNI) documents—are often inadequate to guide physicians in making decisions about critical interventions. These factors can lead to gaps in knowledge regarding patient preferences.”

Several factors can compound the problems related to end-of-life care in the ED, including the complexity of medical conditions among the aging population and technologic advances that offer an increasing number of options for intervention. The Physician Orders for Life-Sustaining Treatment (POLST) was developed to provide a way for patients to clearly inform caregivers about their specific treatment preferences if they develop a serious or end-stage illness.

In 1991, the Center for Ethics in Health Care at Oregon Health Sciences University convened a task force to address standardized portable medical orders for patients with progressive, chronic illnesses with regard to life-sustaining medical treatments. In 1993, the university adopted the acronym POLST. Throughout the United States, POLST documents have also been referred to as physician orders for scope of treatment, medical orders for scope of treatment, and medical orders for life-sustaining treatment, but these all share the same core elements and have similar form design.

POLST-EM-Issues-Callout

Research Supports POLST

Early studies have shown that POLST effectively increases care that is delivered in accordance with patient wishes, according to Dr. Venkat. This was recently described in an article published in the Annals of Emergency Medicine. In the article, the authors note that POLST documents offer physicians important improvements over traditional DNR/DNI orders in the communication and implementation of patient end-of-life care preferences for life-sustaining therapies. Use of POLST may also help clinicians improve the quality of care administered.

According to Dr. Venkat, there are several ethical issues to consider when using documents pertaining to end-of-life care preferences, including those expressed in POLST forms (Table 1). “When patients have the capacity to make decisions, emergency physicians should confirm treatment preferences listed in POLST forms to ensure that they’re still appropriate,” he says. “If changes are made to POLST, they should be discussed with relevant family members and other providers whenever possible.” Patients with intact decision-making capacity have the authority to override previous advanced planning documents.

Addressing Challenges

Ideally, POLST forms should accompany patients and have the authority to represent the patient’s end-of-life care preferences in all clinical settings. However, POLST forms are not perfect, and there are many challenges that may occur while trying to manage patients with these forms (Table 2). “It’s important to not lose sight of the spirit of what POLST forms are intended to do,” says Dr. Venkat. “Emergency physicians need a solid understanding about the use of POLST forms and may also need urgent administrative, legal, or ethical consultations.”

Implementing POLST in EDs is one step toward developing and adopting these forms for local use. “We need to educate healthcare professionals on how to use these forms with patients when discussing end-of-life care,” adds Dr. Venkat. “It’s also important to work with hospital administration when using POLST forms to direct treatment because not all clinical scenarios will be addressed in these documents.”

Future Considerations

More outcomes research is needed on the use of POLST to capture patient preferences and to assess the quality of end-of-life care that is delivered. As POLST documents become more readily available electronically, it will be important to consider privacy concerns and the legal standing of using POLST. “It’s also important to find ways to incentivize physicians to discuss long-term goals of care with patients and execute POLST forms,” Dr. Venkat says.

A library of resources is available on www.polst.org to help states that wish to develop a POLST program. Training videos, brochures, provider and consumer guides, implementation checklists, and sample forms are included on the website. Dr. Venkat recommends using these resources because POLST has the potential to enhance accuracy and penetration over advance directives and DNR/DNI documents. “Although it may be challenging to develop these programs, doing so can push the paradigm forward toward improving outcomes and quality of care,” he says. “In the coming years, we’re likely to see POLST documents more frequently. As such, we should learn to recognize, interpret, and implement them appropriately.”

Readings & Resources (click to view)

Jesus JE, Geiderman JM, Venkat A, et al; on behalf of the ACEP Ethics Committee. Physician orders for life-sustaining treatment and emergency medicine: ethical considerations, legal issues, and emerging trends. Ann Emerg Med. 2014;64:140-144. Available at: http://www.sciencedirect.com/science/article/pii/S0196064414002200.

Perkins HS. Controlling death: the false promise of advance directives. Ann Intern Med. 2007;147:51-57.

 Jesus JE, Allen MB, Michael GE, et al. Preferences for resuscitation and intubation among patients with do-not-resuscitate/do-not-intubate orders. Mayo Clin Proc. 2013;88:658-665.

Hickman SE, Sabatino CP, Moss AH, et al. The POLST (Physician Orders for Life-Sustaining Treatment) paradigm to improve end-of-life care: potential state legal barriers to implementation. J Am Soc Law Med Ethics. 2008;36:119-140.

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