Concordance of Out-of-Hospital and Emergency Department Cardiac Arrest Resuscitation With Documented End-of-Life Choices in Oregon

Life-sustaining treatment decisions and family evaluations of end-of-life care for Veteran decedents in Department of Veterans Affairs nursing homes

BACKGROUND

Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes.

METHODS

Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality.

RESULTS

LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses.

CONCLUSIONS

Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.

An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go?

OBJECTIVES

POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research.

DESIGN

Integrative review.

SETTING AND PARTICIPANTS

Not applicable.

METHODS

We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization.

RESULTS

Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified.

CONCLUSIONS AND IMPLICATIONS

Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.

Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions

Objective: This study aims to evaluate the potential impact of addressing goals-of-care (GOC) with selected patients in the emergency department (ED), GOC documentation, hospital utilization, and patient satisfaction. Method: This is a single-center, retrospective, and prospective, observational convenience-sample study. ED registered nurses (ED RNs) received standardized GOC conversation training. Their selection criteria included a selection interview, a minimum of 3 years of ED clinical experience, and current employment in the ED. ED RNs used a standardized GOC questionnaire. Patient inclusion criteria included age ≥18 years and one or more of the following: chronic kidney disease ≥ stage III, congestive heart failure with an ejection fraction ≤ 40%, chronic obstructive pulmonary disease with home oxygen use, and/or malignancy with metastasis. GOC conversations were recorded in the electronic medical record (EMR). Physician Orders for Life-Sustaining Treatment (POLST) forms were completed as appropriate. Select individual patient data for the 12 months prior to the conversation were compared with the following 12 months. Results: Over 6 months, 94 of 133 patients who were approached consented to the GOC discussion with the RN. All 94 enrolled patients had their GOC recorded into the EMR. One-third already had a completed POLST form prior to ED arrival. 50% without a POLST on ED arrival left with a completed POLST. Eighty-four patients survived the index visit and 46 patients survived to study completion. Patient satisfaction with the interaction was high: In the cohort who survived past the index visit, 95% rated their experience at 4/5 or 5/5 (Likert scale, 5: strongly agree, 1: strongly disagree). In the survival-to-study completion cohort, 100% rated their experience as 4/5 or 5/5. Subsequent median ED visits decreased by 15% (1.0-4.0 interquartile range). There were no statistically significant changes in hospitalizations (both decreased by 25%, 0-3.0) or intensive care unit admissions (0%, 0-0). Conclusions: An ED RN-led GOC conversation had high patient satisfaction and 100% GOC documentation in the EMR. There was a significant increase in ED POLST form completion. There were no significant changes noted in subsequent hospitalizations, length of hospitalization, or intensive care unit utilization.

A Statewide Survey to Understand Barriers to Utilization of the Medical Orders for Scope of Treatment Form among Emergency Medical Service Providers

Background: Advance care planning allows communication of end-of-life goals. The Kentucky medical orders for scope of treatment (MOST) form became a legal medical order in 2015. The Kentucky MOST Coalition formed in 2017 to implement MOST. Objectives: In 2019, Kentucky MOST Coalition members developed a survey to determine emergency medical services (EMS) providers' understanding and barriers to utilization of MOST. Design: The Kentucky Board of EMS e-mailed the survey to its members. The survey was voluntarily completed by EMS providers. The data were analyzed by Kentucky MOST Coalition. Results: A majority of participants had never (72%) encountered a MOST form. In addition, 69% said they had never received MOST training. However, 60% knew that "the MOST form is a physician order and shall be followed in all settings." Conclusions: The majority of the EMS providers knew basic information about MOST. However, accessibility and education were barriers to utilization of MOST. EMS providers need continuing education. Education surrounding MOST can help to ensure a person-centered approach.

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions

BACKGROUND

Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions.

METHODS

This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed.

RESULTS

There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing.

CONCLUSION

The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

BACKGROUND

Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.

METHODS

PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.

DISCUSSION

The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

Intergenerational Decision Making: The Role of Family Relationships in Medical Decision Making

A symposium held at the 42nd annual Society for Medical Decision Making conference on October 26, 2020, focused on intergenerational decision making. The symposium covered existing research and clinical experiences using formal presentations and moderated discussion and was attended by 43 people. Presentations focused on the roles of pediatric patients in decision making, caregiver decision making for a child with complex medical needs, caregiver involvement in advanced care planning, and the inclusion of spillover effects in economic evaluations. The moderated discussion, summarized in this article, highlighted existing resources and gaps in intergenerational decision making in four areas: decision aids, economic evaluation, participant perspectives, and measures. Intergenerational decision making is an understudied and poorly understood aspect of medical decision making that requires particular attention as our society ages and technological advances provide new innovations for life-sustaining measures across all stages of the lifespan.

The influence of POLST on treatment intensity at the end of life: A systematic review

BACKGROUND

Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty.

METHODS

We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life).

RESULTS

Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes.

CONCLUSION

We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.

TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care?

OBJECTIVE

The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM).

METHODS

Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% response rate), resuscitation responses for correct treatment decisions.

RESULTS

The survey response rate was 85%. Approximately half of emergency medical technician (EMT) respondents were EMT basic, and half EMT respondents were paramedic, with an average age of 42 years. Less than half had previous POLST/LW training averaging 2 hours. Consensus failed to be reached for stand-alone documents. For clinical scenarios, responses to POLST documents specifying do not resuscitate/comfort measures only or cardiopulmonary resuscitation/full treatment exceeded 80% for code status designation and correct resuscitation decisions. Other POLST resuscitation/treatment combinations showed more disparate responses, and most benefited from VM with changes in responses of 20% or more (P ≤ 0.025). Code status responses to LW-based scenarios evidenced a nonconsensus majority (79%-83%) that was significantly affected with VMs (≥12%, P ≤ 0.004); half evidenced large changes in resuscitation decisions (49%, P < 0.001).

CONCLUSIONS

Document clarity, judged by consensus response, was rarely evidenced. video message/testimonial seems to be a helpful aid to both POLST and LWs. Standardized education and training reveal opportunities to improve patient safety to ensure patient wishes.

Hospice and Comfort Care Patient Utilization of Emergency Medical Services

Introduction: Emergency medical services (EMS) were designed to prevent death and disability. When hospice patients call 9-1-1, it can create challenging scenarios for EMS providers, patients, and families. The objective of this investigation is to understand the characteristics of hospice and comfort care patient EMS utilization in Alameda County, California. Methods: This is a 15-month (7/1/2019-10/1/2020) retrospective observational study in Alameda County using electronic patient care reports (PCRs). The search terms "hospice" and "comfort measures only" were applied to PCR narratives. Results: Of the 237,493 EMS provider response calls, 534 (0.2%) were for hospice and comfort care patients. One hundred seventy-four (32.6%) calls were from skilled nursing facilities versus 343 (64.2%) from private residences. Among the most common primary impressions were respiratory complaints (96; 18.0%), altered mental status (96; 18.0%), weakness (58; 10.9%), and cardiac arrest (45; 8.4%). The most common interventions included blood glucose (244; 45.7%), electrocardiogram (181; 33.9%), and intravenous placement (170; 31.8%). Of note, eight (1.5%) patients received cardiopulmonary resuscitation, and an additional eight (1.5%) patients were intubated endotracheally or received a supraglottic airway device for intubation. Sixty-eight (12.7%) patients received medications, the most common of which were fentanyl (17; 3.2%) and albuterol (16; 3.0%). Of note, five (0.9%) patients received naloxone. Ultimately, 468 (87.6%) patients were transported by EMS. Of the 33 (6.1%) patients who died on the scene, three received resuscitation attempts. Conclusion: Although EMS providers encounter hospice and comfort care patients infrequently, awareness of hospice services and comprehensive end-of-life care communication skills with patients and family should be an important part of EMS.

End-of-Life Orders, Resource Utilization, and Costs Among Injured Older Adults Requiring Emergency Services

BACKGROUND

Portable Orders for Life-Sustaining Treatment (POLST) are increasingly utilized to assist patients approaching the end of life in documenting goals of care. We evaluated the association of POLST, resource utilization, and costs to 1 year among injured older adults requiring emergency services.

METHODS

This was a retrospective cohort of injured older adults ≥65 years with continuous Medicare fee-for-service coverage transported by emergency medical services (EMS) in 2011 across 4 counties in Oregon. Data sources included EMS, Medicare claims, vital statistics, and state POLST, inpatient and trauma registries. Outcomes included hospital admission, receipt of aggressive medical interventions, costs, and hospice use. We matched patients on patient characteristics and comorbidities to control for bias.

RESULTS

We included 2116 patients of which 484 (22.9%) had a POLST form prior to 911 contact. Of POLST patients, 136 (28.1%) had orders for full treatment, 194 (40.1%) for limited interventions, and 154 (31.8%) for comfort measures. There were no significant associations for care during the index event. However, in the year after the index event, patients with care limitations had higher adjusted hospice use (limited interventions OR 1.7 [95% CI: 1.2-2.6]; comfort OR, 2.0 [95% CI: 1.3-3.0]) and lower adjusted post-discharge costs (no POLST, $32,399 [95% CI: 30,041-34,756]; limited interventions, $18,729 [95% CI: 12,913-24,545]; and comfort $15,593 [95% CI: 12,091-19,095]). There were no significant associations for all other outcomes.

CONCLUSIONS

Care limitations specified in POLST forms among injured older adults transported by EMS are associated with increased use of hospice and decreased costs to 1 year.

The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective

No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.

Factors associated with concordance between POLST orders and current treatment preferences

BACKGROUND

POLST is widely used to document the treatment preferences of nursing facility residents as orders, but it is unknown how well previously completed POLST orders reflect current preferences (concordance) and what factors are associated with concordance.

OBJECTIVES

To describe POLST preference concordance and identify factors associated with concordance.

DESIGN

Chart reviews to document existing POLST orders and interviews to elicit current treatment preferences.

SETTING

POLST-using nursing facilities (n = 29) in Indiana.

PARTICIPANTS

Nursing facility residents (n = 123) and surrogates of residents without decisional capacity (n = 152).

MEASUREMENTS

Concordance was determined by comparing existing POLST orders for resuscitation, medical interventions, and artificial nutrition with current treatment preferences. Comfort-focused POLSTs contained orders for do not resuscitate, comfort measures, and no artificial nutrition.

RESULTS

Overall, 55.7% (123/221) of residents and 44.7% (152/340) of surrogates participated (total n = 275). POLST concordance was 44%, but concordance was higher for comfort-focused POLSTs (68%) than for non-comfort-focused POLSTs (27%) (p < 0.001). In the unadjusted analysis, increasing resident age (OR 1.04, 95% CI 1.01-1.07, p < 0.01), better cognitive functioning (OR 1.07, 95% CI 1.02-1.13, p < 0.01), surrogate as the decision-maker (OR 2.87, OR 1.73-4.75, p < 0.001), and comfort-focused POLSTs (OR 6.01, 95% CI 3.29-11.00, p < 0.01) were associated with concordance. In the adjusted multivariable model, only having an existing comfort-focused POLST was associated with higher odds of POLST concordance (OR 5.28, 95% CI 2.59-10.73, p < 0.01).

CONCLUSIONS

Less than half of all POLST forms were concordant with current preferences, but POLST was over five times as likely to be concordant when orders reflected preferences for comfort-focused care. Findings suggest a clear need to improve the quality of POLST use in nursing facilities and focus its use among residents with stable, comfort-focused preferences.

The living will: Patients should be informed of the risks

Living wills are designed to ensure that patients' preferences will be respected at the end of life should they lose capacity to make decisions. However, data on living will use suggest there are barriers to achieving this objective. Moreover, there is evidence that completion of a living will creates a risk of an unwanted outcome: the potential for premature withdrawal of interventions. We suggest a multifaceted approach to improve the ability of living wills to achieve their goals. However, acknowledgment of the current reality should oblige providers offering a living will to their patients to present a balanced view of living wills that includes enumeration of the risk, barriers to achieving the purported benefits, and alternatives to completing a living will, in addition to discussion of the potential benefits. This requires a change in current practice that would encourage shared decision making regarding whether completing a living will or other type of advance directive is desired by the patient and discourage the proliferation of living wills completed without providing these important advantages and disadvantages to the patient.

Are We Getting What We Really Want? A Systematic Review of Concordance Between Physician Orders for Life-Sustaining Treatment (POLST) Documentation and Subsequent Care Delivered at End-of-Life

BACKGROUND

Physician Orders for Life-Sustaining Treatments (POLST) is an advance care planning (ACP) tool that is designed to facilitate End-of-Life (EoL) care discussions between a medical provider and a terminally ill patient. It is often used as a tool to translate care wishes into a medical order, which can be honored across healthcare settings. With an increased utilization of the POLST paradigm in various healthcare settings along with continued dissemination across the nation, it is critical to examine whether documented wishes on POLST are concordant with subsequent care delivered. Purpose of this article was to examine concordance rate between POLST and subsequent care delivered in any care settings and communities.

DESIGN

Systematic review.

RESULTS

Of 1,406 articles identified, 10 articles met inclusion criteria. Together, included studies represent 5,688 POLST forms reviewed from individuals residing in a total of 126 nursing care facilities, 9 elderly care centers, 4 community settings, and 2 hospitals. Preference for cardiopulmonary resuscitation and actual delivery/ withholding of resuscitation was the most observed intervention in study of concordance (n = 8). It is also where highest concordance rate (97.5%) was reported. Seven studies compared care provided during EoL and the level of medical intervention requested on POLST forms (91.17% concordance). Preference to use artificial nutrition/ hydration, and actual delivery was 93.0% (n = 4 studies), and antibiotics use preference and delivery was 96.5% (reported in 4 studies).

CONCLUSION

Published literature evidence suggests that EoL care wishes documented on POLST forms were largely concordant with subsequent care delivered. Additional research is needed to evaluate concordance between POLST documentation and care received among POLST users, who experienced multiple care transitions across healthcare settings, or across state during EoL care journey.

Determination of the characteristics and outcomes of the palliative care patients admitted to the emergency department

OBJECTIVES

Terminally ill patients in need of palliative care present to emergency departments. This study aims to identify the usage level of the emergency departments by patients in need of palliative care, along with their experienced symptoms, preferences, needs, and the subsequent initiatives taken for symptom management.

METHODS

The study was designed as a cross-sectional study and conducted with a group of 208 patients. The Patient Information Form, the Form of the Criteria for Receiving Palliative Care, and the Karnofsky Performance Scale were used for data collection.

RESULTS

This report founda thatcancer patients were the most frequent users of emergency facilities within palliative care patient groups and more than half of those hospitalized patients were subsequently admitted to intensive care units. Patients with poorer functional conditions and in need of further palliative care preferred home care rather than receiving Advanced Cardiac Life Support.

CONCLUSION

This study displays evidence that palliative care patients with a poorer functional condition in need of further palliative care should be able to spend the last days of their lives at home with their families rather than in the exhausting and crowded environment of the emergency departments. Furthermore, healthcare policymakers should actively support palliative care as well as taking the necessary actions to mitigate the burden placed on hospital resources.

Underutilization of Portable Orders for Life-Sustaining Treatment at Discharge from Hospital: Observational Study at US Academic Trauma Center

BACKGROUND

Decisions to limit use of life-sustaining treatment occur frequently during hospitalizations, and portable medical orders (also known as Portable Orders for Life-Sustaining Treatment (POLST)) can ensure that patient preferences regarding resuscitation are followed after discharge.

OBJECTIVE

To determine the frequency and predictors of completion of POLST orders for adults with change during hospitalization in resuscitation status to Do Not Resuscitate.

DESIGN

Retrospective observational study at level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All adults (18 years or older) hospitalized between June 2017 and June 2018, inclusive, with code status changed from Full Code to DNR. For patients with more than one hospitalization during this study interval, only the first hospitalization when DNR was ordered was included in this analysis.

MAIN MEASURES

Completion of POLST orders by time of discharge.

KEY RESULTS

From 2017 to 2018, 160 adults had a change from Full Code to DNR status during index hospitalization and survived to discharge, most (156 patients) to a nursing care facility. Of these, only 50 (31.2%) had POLST orders provided at discharge. Documentation of informed refusal of intubation in addition to DNR status was a significant predictor (OR 4.1, 99% CI 1.5-11.0) of POLST orders on discharge, as was admission to a medical service compared with non-medical service (OR 3.2, 99% CI 1.1-12.2). Palliative care consultants, rather than primary providers on the hospital services, completed most POLST orders.

CONCLUSIONS

Despite primary hospital providers engaging in conversations regarding resuscitation and entering DNR orders during hospitalization, the majority of patients in our study discharged to other care facilities without POLST orders. POLST orders are a simple palliative care tool available to primary hospital providers to help ensure continuity of plan of care at discharge for patients who wish to avoid invasive life-sustaining treatments and/or cardiopulmonary resuscitation.

Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans' Care Preferences

BACKGROUND

On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set.

OBJECTIVE

Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion.

DESIGN

Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score.

SUBJECTS

All veterans with VA utilization between July 1, 2018, and January 31, 2019.

MAIN MEASURES

Completed LST templates, goals and LST preferences, and predictors of documentation.

RESULTS

LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation.

CONCLUSIONS

LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs.

Surrogate Preferences on the Physician Orders for Life-Sustaining Treatment Form

BACKGROUND AND OBJECTIVES

The purpose of this study is to compare treatment preferences of patients to those of surrogates on the Physician Orders for Life-Sustaining Treatment (POLST) forms.

RESEARCH DESIGN AND METHODS

Data were collected from a sequential selection of 606 Massachusetts POLST (MOLST) forms at 3 hospitals, and corresponding electronic patient health records. Selections on the MOLST forms were categorized into All versus Limit Life-Sustaining Treatment. Multivariable mixed effects (grouped by clinician) logistic regression models estimated the impact of using a surrogate decision maker on choosing All Treatment, controlling for patient characteristics (age, severity of illness, sex, race/ethnicity), clinician (physician vs non-physician), and hospital (site).

RESULTS

Surrogates signed 253 of the MOLSTs (43%). A multivariable logistic regression model taking into consideration patient, clinician, and site variables showed that surrogate decision makers were 60% less likely to choose All Treatment than patients who made their own decisions (odds ratio = 0.39 [95% confidence interval = 0.24-0.65]; p < .001). This model explained 44% of the variation in the dependent variable (Pseudo-R2 = 0.442; p < .001); mixed effects logistic regression grouped by clinician showed no difference between the models (LR test = 4.0e-13; p = 1.00).

DISCUSSION AND IMPLICATIONS

Our study took into consideration variation at the patient, clinician, and site level, and showed that surrogates had a propensity to limit life-sustaining treatment. Surrogate decision makers are frequently needed for hospitalized patients, and nearly all states have adopted the POLST. Researchers may want study decision-making processes for patients versus surrogates when the POLST paradigm is employed.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records

OBJECTIVE

The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders.

METHODS

We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA.

RESULTS

Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients.

CONCLUSIONS

Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.

The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department

STUDY OBJECTIVE

Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED).

METHODS

This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment.

RESULTS

A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61).

CONCLUSION

Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

Demonstrating the impact of POLST forms on hospital care requires information not contained in state registries

Background

Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging.

Objectives

To demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects.

Design

Prospective cohort study.

Setting and participants

Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission.

Results

Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10).

Conclusion

Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.

Exploring provider-surrogate communication during POLST discussions for individuals with advanced dementia

OBJECTIVES

This qualitative descriptive study explored provider-surrogate communication during Physician Orders for Life-Sustaining Treatment (POLST) discussions for patients with advanced dementia.

METHODS

Data from participant observations and audio-recordings of ten POLST discussions were analyzed using directed content analysis within the context of an existing conceptual model of Communication and Surrogate Decision Making.

RESULTS

Surrogates primarily focused on making sense of the clinical information about life-sustaining treatments during POLST conversations. Providers delivered clinical information about the trajectory of dementia, life-sustaining treatments, and/or features of POLST. They also demonstrated emotional support, by valuing what the surrogate said, acknowledging the surrogate's emotions, listening carefully, understanding the patient as a person, and eliciting questions. However, providers rarely conveyed comprehensive information about the patient's current condition and end-of-life treatment options. Also, open communication of expectations and preferred decision-making roles was rarely observed during the discussions.

CONCLUSION

Findings highlight areas that require providers' attention to conduct effective communication, such as delivering comprehensive information about life-sustaining treatments including discussion of risks and benefits in the context of dementia. Findings also support the use of the conceptual model as a framework to examine provider-surrogate communication in the context of POLST discussions, advanced dementia, and non-hospital settings. Additional research is necessary to confirm these findings in larger, more diverse groups of patients, surrogates, and providers.

Injured Older Adults Transported by Emergency Medical Services: One Year Outcomes by POLST Status

Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. We linked multiple data sources to EMS records, including: the Oregon POLST Registry, Medicare claims data, Oregon Trauma Registry, Oregon statewide inpatient data, and Oregon vital statistics records. We describe patient and event characteristics by POLST status at time of 9-1-1 contact, subsequent changes in POLST forms, and mortality to 12 months. Results: Of 7,055 injured older adults, 1,412 (20.0%) had a registered POLST form at the time of 911 contact. Among the 1,412 POLST forms, 390 (27.6%) specified full orders, 585 (41.4%) limited interventions, and 437 (30.9%) comfort measures only. By one year, 2,471 (35%) patients had completed POLST forms. Among the 4 groups (no POLST, POLST-full orders, POLST-limited intervention, POLST-comfort measures), Injury Severity Scores were similar. Mortality differences were present by 30 days (5.0%, 4.6%, 8.0%, and 13.3%, p < 0.01) and were greater by one year (19.5%, 23.9%, 35.4%, and 46.2%, p < 0.01). Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up.

Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals

For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.

Nurse practitioners' completion of Physician Orders for Scope of Treatment forms in West Virginia: A secondary analysis of 12 months of data from the state registry

BACKGROUND AND PURPOSE

Advanced care planning documents, such as the Physician Orders for Life-Sustaining Treatment (POLST), require authorized medical provider signatures; only recently have nurse practitioners (NPs) been authorized to sign these forms. Recent legislation in West Virginia (WV) granting NPs signatory authority on POLST forms and the creation of a statewide registry provides an opportunity to examine the completion rates. The aim of this study was to investigate how recent legislation allowing NPs signatory authority for POLST forms has affected POLST completion.

METHODS

Data were obtained from the WV statewide registry of POST forms completed by all authorized personnel. Forms submitted by NPs were compared with those completed by physicians on patient demographics, setting, resuscitation status, level of medical intervention, and errors. Variables were cross-tabulated by provider type to determine whether and how NP POST completion differed from that of physicians.

CONCLUSIONS

Forty-five NPs submitted 430 POST forms to the WV registry, which constituted 14.4% of the POST forms received. Ten NPs in community and hospital specialist palliative care teams submitted more than two thirds of these 430 forms. Nurse practitioner-completed POST forms were more likely to order do not resuscitate and comfort measures than POST forms ordered by physicians (both p < .001) and to be without errors (p < .001).

IMPLICATIONS FOR PRACTICE

Nurse practitioners practicing in specialist palliative care roles in communities and hospitals have embraced the use of POST and followed through on complete and accurate completion of the forms. With this signatory authority, primary and specialist NPs have the potential to improve end-of-life care.

Assessing concordance between patient preferences in advance care plans and in-hospital care

Objective The aims of this study were to assess: (1) concordance between patient preferences stated in advance care plans (ACPs) and hospital care over the subsequent 12 months; (2) change in preferences over time; (3) justifications for discordant care; and (4) effects of ACP completion on hospital utilisation. Methods A retrospective study was conducted of 198 patients with an ACP form registered with an ACP registry and tagged with a hospital unique record number. Data collected from ACP forms and hospital records comprised ACP completion and revisions, care preferences, patient characteristics and hospital care. Instances of care discordant with preferences were analysed as Type A (no ascertainable justification) and Type B (direct patient request or appropriate clinical indications). In a survivor subset, hospital utilisation was compared before and after ACP completion. Results Mean (± s.d.) patient age was 79.5±11.8 years. Patients had a mean (± s.d.) of 5.5±2.5 comorbidities and 90 (46.4%) died within the 12 months after ACP completion. Most ACPs (130; 65.5%) were completed during index hospitalisation and 13 (6.5%) underwent revision, on average, 6.8 months later, all related to rescinding request for cardiopulmonary resuscitation. Hospital care was fully concordant for 154 (77.8%) patients, with 39 (22.2%) receiving 60 instances of discordant care (15 (25%) Type A, 45 (75%) Type B), mostly related to surgical procedures (20; 33%) and intravenous fluids or antibiotics (26; 43%). Patients receiving discordant care had higher mortality (77% vs 45%; P&lt;0.001) and more rapid response team activations (34% vs 13%; P=0.001) at 12 months than patients with concordant care. Among the 108 confirmed survivors at 12 months after ACP completion, emergency department presentations and hospital admissions per patient had decreased by ≥50% (P&lt;0.001) and hospital days had decreased by 25% (P=0.042) compared with the 12 months before ACP completion. Conclusion Most patients completing an ACP received hospital care fully concordant with their stated preferences, with few revising their preferences over time. Discordant care mostly related to justified supportive treatments or surgical procedures. Among survivors, ACP completion was associated with decreased use of hospital care. What is known about the topic? ACPs that list patient preferences and care goals relieve family and patient distress and uncertainty regarding future care decisions as death approaches, decrease unwanted medical interventions and hospitalisations, and are associated with more patients dying at home. However, uncertainty surrounds the extent to which in-patient care provided to patients’ concords with preferences stated in ACPs, which preferences are most adhered to, and whether preferences change over time, warranting revision of ACPs. What does this paper add? This retrospective study of 198 patients completing an ACP, of whom almost half died within the following 12 months, showed that more than 75% received hospital care fully concordant with their stated preferences and, for decedents, most died at their preferred place of death. Relatively few patients changed their documented preferences over time, and all changes were for less use of cardiopulmonary resuscitation (CPR). Instances of discordant care mostly related to the administration of supportive treatments or surgical procedures and most were justified on the basis of patient request or appropriate clinical indications. Among 108 survivors, the number of emergency department presentations and hospital admissions per patient at 12 months after ACP completion was half those seen in the 12 months before ACP completion, whereas hospital days per patient decreased by 25%. What are the implications for practitioners? Encouraging patients with progressive chronic disease to complete an ACP reduces their risk of receiving care they do not want, reflected in decreased use of hospital care. Preferences stated in ACPs are mostly stable over time and, if changed, tend to become more conservative in terms of CPR. Conversely, preferences stated in the ACP do not, as circumstances change, bind patients or clinicians to withholding care that relieves symptoms or prevents major morbidity in the short term.

The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department

Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.

Changes Over Time in the Oregon Physician Orders for Life-Sustaining Treatment Registry: A Study of Two Decedent Cohorts

Background: The Physician Orders for Life-Sustaining Treatment (POLST) began in Oregon in 1993 and has since spread nationally and internationally.

Objectives: Describe and compare demographics and POLST orders in two decedent cohorts: deaths in 2010–2011 (Cohort 1) and in 2015–2016 (Cohort 2).

Design: Descriptive retrospective study.

Setting/Subjects: Oregon decedents with an active form in the Oregon POLST Registry.

Measurements: Oregon death records were matched with POLST orders. Descriptive analysis and logistic regression models assess differences between the cohorts.

Results: The proportion of Oregon decedents with a registered POLST increased by 46.6% from 30.9% (17,902/58,000) in Cohort 1 to 45.3% (29,694/65,458) in Cohort 2. The largest increase (83.3%) was seen in decedents 95 years or older with a corresponding 78.7% increase in those with Alzheimer's disease and dementia, while the interval between POLST form completion and death in these decedents increased from a median of 9–52 weeks. Although orders for do not resuscitate and other orders to limit treatment remained the most prevalent in both cohorts, logistic regression models confirm a nearly twofold increase in odds for cardiopulmonary resuscitation and full treatment orders in Cohort 2 when controlling for age, sex, race, education, and cause of death.

Conclusion: Compared with Cohort 1, Cohort 2 reflected several trends: a 46.6% increase in POLST Registry utilization most marked in the oldest old, substantial increases in time from POLST completion to death, and disproportionate increases in orders for more aggressive life-sustaining treatment. Based on these findings, we recommend testing new criteria for POLST completion in frail elders.

Building A Longitudinal Cohort From 9-1-1 to 1-Year Using Existing Data Sources, Probabilistic Linkage, and Multiple Imputation: A Validation Study

OBJECTIVE

The objective was to describe and validate construction of a population-based, longitudinal cohort of injured older adults from 9-1-1 call to 1-year follow-up using existing data sources, probabilistic linkage, and multiple imputation.

METHODS

This was a descriptive cohort study conducted in seven counties in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. The primary cohort included all injured adults ≥ 65 years served by 44 emergency medical services (EMS) agencies. We used nine existing databases to assemble the cohort, including EMS data, two state trauma registries, two state discharge databases, two state vital statistics databases, the Oregon Physician Order for Life-Sustaining Treatment registry, and Medicare claims data. We matched data files using probabilistic linkage and handled missing values with multiple imputation. We independently validated data processes using 1,350 randomly sampled records for probabilistic linkage and 3,140 randomly sampled records for variables created from existing data sources.

RESULTS

There were 15,649 injured older adults in the primary cohort, with 13,661 (87.3%) total matched records and 9,337 (59.7%) matches to the index ED/hospital visit. The sensitivity of linkage was 99.9% (95% confidence interval [CI] = 99.3%-100%) for any match and 98.3% (95% CI = 96.2%-99.4%) for index event matches. The specificity of linkage was 95.7% (95% CI = 93.7%-97.2%) for any match and 100% (95% CI = 99.2%-100%) for index event matches. Name, date of birth, home zip code, age, and hospital had the highest yield for linkage. Patients with matched records tended to be higher acuity than unmatched patients, suggesting selection bias if unmatched patients were excluded. Compared to hand-abstracted values, the sensitivity of electronically derived variables ranged from 18.2% (abdominal-pelvic Abbreviated Injury Scale score ≥ 3) to 97.4% (in-hospital mortality), with specificity of 88.0% to 99.8%.

CONCLUSIONS

A population-based emergency care cohort with long-term outcomes can be constructed from existing data sources with high accuracy and reasonable validity of resulting variables.

The Ethics of Real-Time EMS Direction: Suggested Curricular Content

Ethical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.

BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The ethics of real-time EMS direction: suggested curricular content. Prehosp Disaster Med. 2018;33(2):201–212.

Quality indicators in the care of older persons in the emergency department: A systematic review of the literature

OBJECTIVE

A systematic review of the literature was undertaken to assess the methodological quality of existing quality indicators (QIs) for the emergency department (ED) care of older persons.

METHODS

MEDLINE, CINAHL, EMBASE and grey literature were searched. Articles were included if they addressed ED care of persons aged ≥65 years and defined a QI amenable to influence by ED providers. The methodological quality of QIs was assessed using relevant items from the Appraisal of Indicators through Research and Evaluation and the QUALIFY tools.

RESULTS

Sixty-one articles were included in the review, with identification of 50 QIs meeting predefined inclusion criteria. Thirty-six of fifty ED QIs for older persons were process indicators. The appraisal instruments' total ratings ranged from 39 to 67%, with only 18 QIs scoring 50% or more for all five domains.

CONCLUSION

There is a need for a balanced, methodologically robust set of QIs for care of older persons in the ED.

Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach

The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.

Do not attempt resuscitation order in Japan

Aim

In Japan, the do not attempt resuscitation (DNAR) order is practised routinely even though no related laws or guidelines exist. This study aimed to clarify the current status of DNAR, reveal existing DNAR‐related issues, and improve the application of DNAR.

Methods

A questionnaire survey of medical institutions in Kanagawa Prefecture (total population, 9,120,000) about the current status of DNAR was carried out.

Results

The results showed that DNAR has been practised at approximately 90% of the hospitals surveyed, but only about 30% have developed in‐hospital DNAR guidelines. Approximately 80% of the hospitals do not involve patients in the decision on their own DNAR orders. Because the DNAR order has not been legislated, it is often unclear whether to resuscitate patients when a request for an ambulance is made for a cardiac arrest at home.

Conclusion

It is necessary for prefectures, municipalities, and local medical control authorities to take the initiative in establishing an ordinance on DNAR orders and developing guidelines.

Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda

BACKGROUND

Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED).

OBJECTIVE

The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED.

METHODS

Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement.

CONCLUSION

Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.

The Role of Advanced Practice Registered Nurses in the Completion of Physician Orders for Life-Sustaining Treatment

Background: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms.

Objective: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms.

Design: Cross-sectional.

Setting/subjects: 226,101 Oregon POLST Registry forms from 2010 to 2015.

Measurements: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA).

Results: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign.

Conclusions: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.

Implementation of a Novel Electronic Health Record-Embedded Physician Orders for Life-Sustaining Treatment System

In April 2015, Oregon Health & Science University (OHSU) deployed a web-based, electronic medical record-embedded application created by third party vendor Vynca Inc. to allow real-time education, and completion of Physician Orders for Life Sustaining Treatment (POLST). Forms are automatically linked to the Epic Systems™ electronic health record (EHR) patient header and submitted to a state Registry, improving efficiency, accuracy, and rapid access to and retrieval of these important medical orders. POLST Forms, implemented in Oregon in 1992, are standardized portable medical orders used to document patient treatment goals for end-of-life care. In 2009, Oregon developed the first POLST-only statewide registry with a legislative mandate requiring POLST form signers to register the form unless the patient opts out. The Registry offers 24/7 emergency access to POLST Forms for Emergency Medical Services, Emergency Departments, and Acute Care Units. Because POLST is intended for those nearing end of life, immediate access to these forms at the time of an emergency is critical. Delays in registering a POLST Form may result in unwanted treatment if the paper form is not immediately available. An electronic POLST Form completion system (ePOLST) was implemented to support direct Registry submission. Other benefits of the system include single-sign-on, transmission of HL7 data for patient demographics and other relevant information, elimination of potential errors in form completion using internalized logic, built-in real-time video and text-based education materials for both patients and health care professionals, and mobile linkage for signature capture.

Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

OBJECTIVES

What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms.

PROCEDURES

MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the "other instructions" section were submitted to content analysis.

RESULTS

Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for "comfort measures only" seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics.

CONCLUSIONS

Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

Timing of POLST Form Completion by Cause of Death

CONTEXT

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.

OBJECTIVES

To determine the influence of cause of death on the timing of POLST form completion and on changes to POLST orders as death approaches.

METHODS

This was a cohort study of 18,285 Oregon POLST Registry decedents who died in 2010-2011 matched to Oregon death certificates.

RESULTS

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.

CONCLUSION

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).

TRIAD VI: how well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms?

BACKGROUND

Physician Orders for Life-Sustaining Treatment (POLST) documents are active medical orders to be followed with intention to bridge treatment across health care systems. We hypothesized that these forms can be confusing and jeopardize patient safety.

OBJECTIVES

The aim of this study was to determine whether POLST documents are confusing in the emergency department setting and how confusion impacts the provision or withholding of lifesaving interventions.

METHODS

Members of the Pennsylvania chapter of the American College of Emergency Physicians were surveyed between September and October 2013. Respondents were to determine code status and treatment decisions in scenarios of critically ill patients with POLST documents who emergently arrest. Combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and levels of treatment (full, limited, comfort measures) were represented. Responses were summarized as percentages and analyzed by subgroup using the Fisher exact test. P = 0.05 was considered significant. We defined confusion in response as absence of consensus (supermajority of 95%).

RESULTS

Our response rate was 26% (223/855). For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Physician age and experience significantly affected response rates; prior POLST education had no impact. In most scenarios depicted, responses reflected confusion over its interpretation.

CONCLUSIONS

Significant confusion exists among members of the Pennsylvania chapter of the American College of Emergency Physicians regarding the use of POLST in critically ill patients. This confusion poses risk to patient safety. Additional training and/or safeguards are needed to allow patient choice as well as protect their safety.

Physician orders for life-sustaining treatment and emergency medicine: ethical considerations, legal issues, and emerging trends

Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.