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POLST orders successfully guide end of life medical treatment

POLST form preferences greatly influence location of death, honor patient’s wishes

Many Americans have strong preferences about the kind of medical treatment they want as they near the end of their lives. No matter the preference, patients and their families want to know that their wishes are being respected.

A new study, published today by researchers at Oregon Health & Science University, shows that the Physician Orders for Life-Sustaining Treatment program—commonly known as POLST—gives seriously ill or frail people a voice in how they are treated in a medical crisis. The study was published online by the Journal of the American Geriatrics Society.

“Because emergency medical service protocol is to provide full treatment including resuscitation and transport to a hospital, Americans who prefer otherwise need to plan in advance and make their wishes known through medical orders such as a POLST form,” said Erik Fromme, M.D., a palliative care specialist with the Knight Cancer Institute at OHSU and lead author on the study. “In this study, we found striking differences in how many patients died in hospitals versus at home depending on how their POLST forms were completed.”

Directions on a POLST form allow patients to request or refuse certain medical treatments such as CPR or intensive care. Patients can avoid unwanted hospitalization by selecting comfort measures only, seek basic medical treatment by selecting limited additional interventions or select full treatment, which includes life support measures in the intensive care unit.

The study utilized 58,000 Oregon death records for people who died of natural causes in Oregon in 2010 and 2011. Of those 58,000 records, nearly 18,000 had a POLST form in the Oregon POLST registry. The study compared location of death with POLST orders for the 18,000 people with a form in the registry. Study results showed that only 6.4 percent of patients who specified comfort measures only orders on their POLST form died in a hospital, while 22.4 percent of patients who chose limited additional interventions died in a hospital and 44.2 percent of patients who chose full treatment died in a hospital. Additionally, 34.2 percent of people with no POLST form died in a hospital.

“This study shows that what is ordered on a POLST form matches the treatment patients receive,” said Susan Tolle, M.D., director of the Center for Ethics in Health Care and professor of medicine at OHSU and senior author on the study. “Those who want full treatment are even more likely to die in the hospital than those who do not have a POLST form. This pattern of receiving more treatment when that was the patient's wish holds true for all 10 of the most common causes of death. Furthermore, patients who have orders for comfort measures only are far more likely to avoid unwanted hospitalizations.”

The POLST Paradigm was conceived more than two decades ago by Oregon health care professionals as a tool for end-of-life planning that emphasizes patients’ wishes about the care they receive. Filling out a POLST form helps individuals with advanced illness or frailty ensure their preferences are honored as medical orders. A POLST form is printed on brightly colored paper and is signed by a patient’s physician, nurse practitioner or physician assistant after a discussion with the patient about their preferred treatment plan. In Oregon, a patient can choose to have their POLST form stored in a secure online registry that emergency personnel can access quickly in a crisis. Participation in POLST and the online registry is completely voluntary.

The POLST study was supported in part by a grant from the Samuel S. Johnson Foundation and by individual donors who support the POLST program through gifts to the OHSU Foundation.

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