Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST Registry.

Physician Orders for Life-Sustaining Treatment (POLST) has become a common means of documenting patient treatment preferences. In addition to orders either for Attempt Resuscitation or Do Not Attempt Resuscitation, for patients not in cardiopulmonary arrest, POLST provides three levels of treatment: Full Treatment, Limited Interventions, and Comfort Measures Only. Oregon has an electronic registry for POLST forms completed in the state. We used registry data to examine the different combinations of treatment orders. We analyzed data from forms signed and entered into the Oregon POLST Registry in 2012. The analysis included 31,294 POLST forms. The mean Registrant age was 76.7 years. 21,396 (68.4%) had Do Not Attempt Resuscitation (DNR) orders and 9900 (31.6%) had orders for "Attempt Resuscitation". The 6 order combinations were: Do Not Resuscitate (DNR)/Comfort Measures Only 10,769 (34.4%), DNR/Limited Interventions 9306 (29.7%), DNR/Full Treatment 1211 (3.9%), Attempt Cardiopulmonary Resuscitation (CPR)/Comfort Measures Only 11 (0.04%), Attempt CPR/Limited Interventions 2281 (7.3%), and Attempt CPR/Full Treatment 7473 (23.9%). The most common order combinations were DNR/Comfort Measures Only, DNR/Limited Interventions and Attempt Resuscitation/Full Treatment. These three makes sense to health professionals. However, other order combinations that require interpretation at the time of a crisis were completed for about 10% of Registrants. These combinations need further investigation.

Schmidt TA ，Zive D ，Fromme EK ，Cook JN ，Tolle SW ... -  《-》

Association between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and in-hospital death in Oregon.

To examine the relationship between Physician Orders for Life-Sustaining Treatment (POLST) for Scope of Treatment and setting of care at time of death. Cross-sectional. Oregon in 2010 and 2011. People who died of natural causes. Oregon death records containing cause and location of death were matched with POLST orders for people with a POLST form in the Oregon POLST registry. Logistic regression was used to measure the association between POLST orders and location of death. Of 58,000 decedents, 17,902 (30.9%) had a POLST form in the registry. Their orders for Scope of Treatment were comfort measure only, 11,836 (66.1%); limited interventions, 4,787 (26.7%); and full treatment, 1,153 (6.4%). Comfort measures only (CMO) orders advise avoiding hospitalization unless comfort cannot be achieved in the current setting; 6.4% of participants with POLST CMO orders died in the hospital, compared with 44.2% of those with orders for full treatment and 34.2% for those with no POLST form in the registry. In the logistic regression, the odds of dying in the hospital of those with an order for limited interventions was 3.97 times as great (95% CI = 3.59-4.39) as of those with a CMO order, and the odds of those with an order for full treatment was 9.66 times as great (95% CI = 8.39-11.13). The association with numbers of deaths in the hospital suggests that end-of-life preferences of people who wish to avoid hospitalization as documented in POLST orders are honored.

Fromme EK ，Zive D ，Schmidt TA ，Cook JN ，Tolle SW ... -  《-》

Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status.

Program was designed to communicate resident/surrogate treatment preferences in the form of medical orders. To assess statewide nursing facility use of the Physician Orders for Life-Sustaining Treatment (POLST) and to identify the patterns of orders documented on residents' POLST forms. Telephone survey; on-site POLST form review. Oregon nursing facilities. One hundred forty-six nursing facilities in the telephone survey; 356 nursing facility residents aged 65 and older at seven nursing facilities in the POLST form review. A telephone survey; onsite POLST form reviews. In the telephone survey, 71% of facilities reported using the POLST program for at least half of their residents. In the POLST form review, do-not-resuscitate (DNR) orders were present on 88% of POLST forms. On forms indicating DNR, 77% reflected preferences for more than the lowest level of treatment in at least one other category. On POLST forms indicating orders to resuscitate, 47% reflected preferences for less than the highest level of treatment in at least one other category. The oldest old (> or = 85, n=167) were more likely than the young old (65-74, n=48) to have orders to limit resuscitation, medical treatment, and artificial nutrition and hydration. The POLST program is widely used in Oregon nursing facilities. A majority of individuals with DNR orders requested some other form of life-extending treatment, and advanced age was associated with orders to limit treatments.

Hickman SE ，Tolle SW ，Brummel-Smith K ，Carley MM ... -  《JOURNAL OF THE AMERICAN GERIATRICS SOCIETY》

The Oregon physician orders for life-sustaining treatment registry: a preliminary study of emergency medical services utilization.

The Physician Orders for Life-Sustaining Treatment (POLST) form translates patient treatment preferences into medical orders. The Oregon POLST Registry provides emergency personnel 24-h access to POLST forms. To determine if Emergency Medical Technicians (EMTs) can use the Oregon POLST Registry to honor patient preferences. Two telephone surveys were developed: one for the EMT who made a call to the Registry and one for the patient or the surrogate. The EMT survey was designed to determine if the POLST form accessed through the Registry changed the care of the patient. The patient/surrogate survey was designed to determine if the care provided matched the preferences on the POLST. When feasible, the Emergency Medical Services (EMS) record was reviewed to determine whether or not treatment was provided. During the study period there were 34 EMS calls with matches to patients' POLST forms, and 23 interviews were completed with EMS callers, for a response rate of 68%. In seven cases (30%) the patient was in cardiopulmonary arrest; one patient had a respiratory arrest with a pulse. Eight respondents (35%) reported that the patient was conscious and apparently able to make decisions about preferences. For 10 cases (44%) the POLST orders changed treatment, and in six instances (26%) they affected the decision to transport the patient. For the 10/11 patients or surrogates interviewed, the care reportedly matched their wishes. This small study suggests that an electronic registry of POLST forms can be used by EMTs to enhance their ability to locate and honor patient preferences regarding life-sustaining treatments.

Schmidt TA ，Olszewski EA ，Zive D ，Fromme EK ，Tolle SW ... -  《JOURNAL OF EMERGENCY MEDICINE》

Timing of POLST Form Completion by Cause of Death.

The physician orders for life-sustaining treatment (POLST) paradigm allows health care professionals to document the treatment preferences of patients with advanced illness or frailty as portable and actionable medical orders. National standards encourage offering POLST orders to patients for whom clinicians would not be surprised if they died in the next year. To determine the influence of cause of death on the timing of POLST form completion and on changes to POLST orders as death approaches. This was a cohort study of 18,285 Oregon POLST Registry decedents who died in 2010-2011 matched to Oregon death certificates. The median interval between POLST completion and death was 6.4 weeks. Those dying of cancer had forms completed nearer death (median 5.1 weeks) than those with organ failure (10.6 weeks) or dementia (14.5 weeks; P < 0.001). More than 90% of final POLST forms indicated orders for no resuscitation and 65.1% listed orders for comfort measures only. Eleven percent of the sample had multiple registered forms during the two years preceding their death, with the form completed nearest to death more likely than earlier forms to have orders for no resuscitation and comfort measures only, although some later forms did have orders for more treatment. More than half of POLST forms were completed in the final two months of life. Cause of death influenced when POLST forms were completed. POLST forms changed in the two years preceding death, more frequently recording fewer life-sustaining treatment orders than the earlier form(s).

Zive DM ，Fromme EK ，Schmidt TA ，Cook JN ，Tolle SW ... -  《-》