Signed orders help patients avoid unwanted ICU care

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Whether or not to receive dialysis in the hospital are among the interventions that can be covered in some patient end-of-life care choices.

Patients with chronic illnesses who have signed medical orders that indicate their wish to limit the types of treatments they receive near the end of life are less likely to receive unwanted intensive care if they are admitted to the hospital. This is the finding of a new study by researchers in the Cambia Palliative Care Center of Excellence at the University of Washington in Seattle.

Nevertheless, more than one third of those who had asked for limited care received treatments they had stipulated they did not want, the researchers found.

Physician Orders for Life Sustaining Treatment, or POLST, is a document generally used by people with an advanced chronic disorder or a terminal illness. It specifies a patient’s wishes on different aspects of end-of-life medical care. In addition to indicating whether or not resuscitation should be attempted if the heart or breathing stop, the document also covers the patient’s decisions about some other medical interventions. Unlike a Living Will, it is signed by a physician and is generally for a patient who has an advanced or progressive illness.

“POLSTs are useful. They can help prevent patients from getting unwanted care,” said Robert Y. Lee, the lead author of the study. “But a significant proportion of these patients who are hospitalized are not getting care that is consistent with their wishes as stated in their POLST orders.” Lee is a physician at UW Medicine’s Harborview Medical Center and an acting instructor of medicine in the Division of Pulmonary, Critical Care and Sleep Medicine at the UW School of Medicine. He researches the delivery of palliative care to seriously ill patients.

This study’s results were published online February 16 in JAMA, the Journal of the American Medical Association. The publication of the paper coincided with Lee’s presentation at the Society of Critical Care Medicine’s 49th Critical Care Congress in Orlando, Florida.

Patient monitors and other medical equipment in a hospital intensive care unit. Getty Images.

Most states now allow patients and their doctors to draw up Physician Orders for Life Sustaining Treatment so that patients with chronic illnesses can stipulate what level of care they want as they near the end of their lives.

Previous research has shown that patients who have completed POLSTs are less likely to receive cardiopulmonary resuscitation, or CPR, less likely to be sent to the hospital and less likely to die in the hospital.

“We already know that POLST forms can prevent unwanted hospitalizations. but not very much is known about what happens when patients with these forms come into the hospital,” said Erin Kross, the senior author of the paper and associate professor of medicine in the Division of Pulmonary, Critical Care and Sleep Medicine at the UW School of Medicine.

To find out, the researchers reviewed the charts of 1818 patients with chronic illness in Washington state who had completed POLSTS and who had been admitted to the hospital in the six months before they died.

The researchers compared the care received by three patient groups: Those who indicated in their POLST that they wanted comfort measures – care to alleviate symptoms – but did not want life-sustaining treatments; those who wanted limited medical interventions, such as antibiotics or intravenous fluids, but not intensive care; and those who wanted full treatment.

They then looked at whether patients were admitted to an intensive care unit, and whether they received four kinds of intensive treatments: mechanical ventilation, renal dialysis, CPR, and drugs called vasopressors. These drugs help maintain a patient’s blood pressure when it falls due to such things as heart failure or sepsis.

Of the patients admitted to the hospital, nearly two-thirds (62%) of those who indicated they wanted full treatment were admitted to the ICU and received intensive treatments during their hospitalization. This would be in line with what they documented that they wanted in their POLSTs. About half (46%) of those with limited intervention orders and about one-third (31%) of those who had orders for comfort measures also went to the ICU.

Overall, more than a third (38%) of those who had requested comfort measures or limited interventions received some form of intensive care that they had asked not to receive, according their POLST orders.

Patients with cancer or dementia, and older patients, were less likely to receive care that they stipulated in their POLST that they did not want. Those patients admitted to the hospital for traumatic injuries were more likely to receive such unwanted care. The researchers noted that POLST orders are not inviolable. Patients, family members or other surrogates can override the POLST and ask for additional treatment.

“The intensive care delivered to patients who asked for limited treatment or comfort measures is not always inappropriate. Circumstances change, and patients and their families may change their minds,” Lee said. “But in many cases it represents a failure of the POLST system.”

POLST forms are not necessarily included in patients’ electronic medical records, for example. Patients and family members may not inform the hospital care team that a patient has a POLST.

Lee noted. “We need to think about how to integrate POLSTs into electronic health records, and educate patients, family members and healthcare providers about how they should be implemented.”

The title of the JAMA paper reporting these findings is “Association of Physician Orders for Life-Sustaining Treatment with ICU Admission Among Patients Hospitalized Near the End of Life.”

This study was supported by the National Heart, Lung, and Blood Institute (HL142211, HL137940, HL125195, HL007287, HL133115), Cambia Health Foundation, and UW Medicine. and a Prince Mahidol Youth Program Award, Bangkok, Thailand. Infrastructure and chart abstraction support was provided by the UW Institute of Translational Health Sciences, which is funded by the National Center for Advancing Translational Sciences through the Clinical and Translational Science AwardsProgram (UL1 TR002319).

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