A new multi-state study has found that nursing home patients participating in a program enabling them to communicate their wishes for end-of-life treatment are far less likely to receive unwanted hospitalizations and medical interventions than patients who don’t participate in the program.
The program, called Physician Orders for Life-Sustaining Treatment (POLST), uses an innovative medical order form signed by physicians, nurse practitioners or physician assistants. POLST allows patients to specify whether they want to receive CPR, hospitalization and treatments like antibiotics, feeding tubes and other medical interventions. POLST was first developed in Oregon in 1990 in response to concerns that traditional Do Not Resuscitate (DNR) orders and Advance Directives do not adequately communicate patients’ wishes for the many treatment decisions they face at the end of their lives.
The study found that patients who indicated on their POLST forms that they wished to receive care primarily focused on relieving their pain and suffering were 59 percent less likely to receive unwanted treatments and interventions, such as hospitalization, than those with only a DNR order. At the same time, the study showed that patients with POLST forms who requested fewer medical interventions continued to receive a similar level of pain management compared with patients without POLST forms.
“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, Ph.D., 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.”
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. 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,” said Susan Tolle, M.D., director of the Center for Ethics in Health Care at Oregon Health & Science University and co-author on the study. “But this study shows that if that’s their preference, POLST helps ensure they’ll receive full treatment. POLST allows patients to tell their health care professionals exactly what they want, so providers know patients’ wishes no matter what level of treatment they are seeking.”
The study was funded by the National Institute of Nursing Research, a component of the National Institutes of Health. 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.
A second study published in the same edition of the journal this month found additional evidence that POLST contributes to patients receiving the end-of-life care they prefer. The study looked at the medical records of 400 patients who died in the hospital, a nursing home and in the community in La Crosse County, Wis..
“This second 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.
“These studies reaffirm our two-decade experience in Oregon that POLST is effective in helping to ensure that the preferences of persons with advanced progressive illness or frailty to have or to limit treatment are honored,” says Patrick Dunn, M.D., co-chair of the Oregon POLST Task Force and executive director of the National POLST Paradigm Task Force.
In the latest effort to further improve the POLST program, the state of Oregon launched the POLST Registry in December 2009. Dunn adds: “The data supports the next innovation in the POLST program, creating the new Oregon POLST Registry.” Thanks to this system, patients who wish their POLST orders to be available on the secure 24/7 electronic registry can be further assured that their treatment preferences will be available in a crisis. More than 25,000 Oregonians’ POLST forms have been submitted to the Registry since the state law became effective. Additional information is available online at www.polst.org or by calling 503 418-4083.
Oregon Health & Science University is the state’s only health and research university, and Oregon’s only academic health center. OHSU is Portland's largest employer and the fourth largest in Oregon (excluding government). OHSU's size contributes to its ability to provide many services and community support activities not found anywhere else in the state. It serves patients from every corner of the state, and is a conduit for learning for more than 3,400 students and trainees. OHSU is the source of more than 200 community outreach programs that bring health and education services to every county in the state.