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.
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.
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.”
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.