POLST Program Enables Patients to Document Wishes for End-of-Life Treatment

New study Links Program to Lower Rates of Unwanted Hospitalization

A new multi-state study has found that nursing home patients who participate in a program that enables them to record their wishes for end-of-life treatment are far less likely to receive unwanted hospitalization and medical interventions than are other patients.

The program, called Physician Orders for Life-Sustaining Treatment (POLST) in most locations, uses an innovative medical order form signed by physicians. The form allows patients to specify whether or not they wish to receive CPR, hospitalization, and treatments like antibiotics, feeding tubes, and other medical interventions. POLST was first developed in Oregon in 1990 to address concerns that traditional Do Not Resuscitate (DNR) orders and other advance directives do not adequately communicate patients' wishes for the cascade of treatment decisions they may face at the end of their lives.

"The POLST program empowers people at a time in their lives when they are at their most fragile and vulnerable," said Sharon A. Brangman, MD, FACP, AGSF, president of the American Geriatrics Society. "With a POLST form in place, the patient's wishes become very clear to all members of the medical team who are responsible for his or her care."

The study found that patients with POLST forms saying they wished to receive care that primarily focused on relieving their pain and suffering were 59 percent less likely to receive unwanted treatments such as hospitalization than those who had had only a DNR order. The study also showed that patients with POLST forms who requested fewer medical interventions continued to receive pain management; when compared to other patients, they were found to receive identical levels of treatment for pain and other symptoms.

"Traditional approaches such as DNR orders don't tell us about a patient's wishes regarding other kinds of treatments. In our study, 98 percent of residents with POLST forms had orders about medical interventions in addition to resuscitation, compared with just 16 percent of residents without POLST forms," said lead author, Susan Hickman, PhD, Associate Professor in the Schools of Nursing at Indiana University and Oregon Health & Science University. "The bottom line is that POLST translates patients' wishes about a range of treatments into medical orders that are easily understood by health care professionals and can be acted upon immediately."

According to Dr. Hickman, POLST is unique because it travels with the patient and applies to his or her care at all times in nursing facilities, hospitals, hospices, and EMS. "The POLST form is not just another piece of paper to juggle. It is part of a coordinated system that helps ensure that a patient's wishes to have-or to decline-medical interventions are honored," she said.

The study was published in the July, 2010 issue of the Journal of the American Geriatrics Society.

On POLST forms, patients may indicate a preference for all available treatments. And in those cases, the study found that patients with a POLST form requesting full treatment received the same level of treatment as those patients with traditional orders requesting full treatment.

"Only about 12 percent of nursing home patients want intensive care. But this study shows that if that's their preference, POLST helps ensure they'll receive full treatment," said Susan Tolle, M.D., Director of the Center for Ethics in Health Care at the Oregon Health & Science University and co-author on the study.

The study, entitled "A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Life-Sustaining Treatment Program" was funded by the National Institute of Nursing Research. It tracked the impact of the POLST program by analyzing the medical records of 1,711 nursing facility patients in Oregon, West Virginia, and Wisconsin. Thirty-two states have now implemented POLST or are developing similar programs. Though the form is similar in each state, the program name can vary. In West Virginia, POLST is referred to as the Physician Orders for Scope of Treatment (POST), and in New York, it's called Medical Orders for Life Sustaining Treatment (MOLST).

"The goal of POLST is to honor treatment preferences of those with advanced illness or frailty. The research indicates the POLST program is achieving this goal," said Alvin H. Moss, M.D., Director of the Center for Health Ethics and Law of West Virginia University, a co-author on the nursing home patient study, and National POLST Paradigm Task Force member. "In addition, POLST serves as a catalyst for conversations in which patients talk with their loved ones and their health care professionals about what they really want."

Another study published in the same edition of the Journal this month found additional evidence that POLST helps patients receive the end-of-life care they prefer. The study looked at the medical records of 400 patients who died in the hospital, nursing home, and community in La Crosse County, Wisconsin.

"Our study found that patients with POLST forms who did not want to be hospitalized had their requests honored 99 percent of the time. In contrast, before the existence of POLST, patients who did not want to be hospitalized only had their wishes met 78 percent of the time," said lead author Bernard J. Hammes Ph.D., Director of Medical Humanities for Gundersen Lutheran Medical Foundation, and Chair of the National POLST Paradigm Task Force.

ABOUT THE NATIONAL POLST PARADIGM TASK FORCE

The task force was convened in September 2004 by the Center for Ethics in Health Care at Oregon Health & Science University to ensure that the treatment preferences of persons with advanced illness are known, communicated, and honored across all health care settings. Members serve developing programs across the U.S. through education, consultation and conduct of research.

To learn more about POLST, go to polst.org.