The centerpiece of the Physicians Orders for Life-Sustaining Treatment (POLST) program is a bright pink form that translates treatment preferences into medical orders. Unlike an advance directive which can be completed at any point in a person's life, the POLST form is geared towards patients in the final stages of their lives when the conditions of their approaching deaths may be apparent. The program began in 1991 with the creation of the POLST Task Force, a group of collaborating Oregon health care providers, including physicians, nurses, hospice care providers and emergency medical personnel. The effort was spearheaded by the Center for Ethics in Health Care at OHSU, along with other Oregon health systems and caregivers.
"Funding from The Greenwall Foundation of New York enabled us to conduct two statewide research studies. The first examined use of the POLST program in nursing homes and the second explored emergency medical technicians experiences with the program in the field," explained Susan Hickman, Ph.D., senior scholar with the Center for Ethics in Health Care and assistant professor in the OHSU School of Nursing. Hickman is lead author on one of the studies and a contributing author on the other.
A telephone survey of Oregon nursing homes found that 82 percent of nursing homes in Oregon use the POLST program for at least some of their residents. Most (71 percent) use the program for a majority of their residents. Chart reviews were conducted at seven Oregon facilities.
"One key finding of the chart reviews was that resuscitation status alone did not provide a complete picture regarding treatment preferences for a range of life-sustaining interventions," explained Hickman. "Traditionally, health care providers have assumed that resuscitation status was a good indicator of preferences for other kinds of treatments. Our findings disprove this assumption. The majority of elderly residents in nursing facilities (88 percent) had POLST forms marked 'do not resuscitate,' reflecting their wish to avoid CPR. However, 'do not resuscitate' does not mean 'do not treat.' In fact, most of these same residents (77 percent) requested more aggressive treatment in at least one other treatment category listed on the POLST form, such as tube feeding, antibiotic use, or hospitalization. We also found that the older a patient was, the less likely they were to want aggressive, life-sustaining measures."
The second study published in the Journal of the American Geriatrics Society examined emergency medical technicians (EMTs) experiences with the POLST Program. This group was surveyed as they are the "front line" providers of emergency medical treatment.
"POLST is used throughout Oregon and commonly recognized by emergency responders. Nearly three-quarters (73 percent) of Oregon EMTs surveyed had treated at least one patient with a POLST form," said Terri Schmidt, M.D., M.S., professor and vice chair of emergency medicine in the OHSU School of Medicine; a researcher with the OHSU Center for Policy and Research in Emergency Medicine at OHSU and lead author of the study. "Respondents reported that the POLST form resulted in a change in standard treatment nearly half of the time (45 percent) and almost all (93 percent) of those surveyed said it was helpful when a patient had no pulse and was not breathing. Most respondents also reported that the form helped them to know what treatments to provide in other medical situations, as well."
"These findings are particularly significant, as the standard treatment protocol requires EMTs to attempt resuscitation and provide aggressive interventions. In contrast, a patient with a POLST form with orders indicating 'do not resuscitate' would not receive cardiopulmonary resuscitation and patients not in cardiac arrest would receive the level of treatment they preferred. One of the unique features of the POLST form is that it helps EMTs know what types of treatments to provide for many different medical circumstances."
The same journal issue also includes a commentary about the nursing home study written by Karl Lorenz, M.D., M.S.H.S., and Joanne Lynn, M.D., M.A., M.S., of RAND Health.
"Hickman et al.'s report in this Journal impressively documents that the POLST is being used widely in Oregon nursing homes and suggests that POLST achieves some important flexibility that the usual DNR orders cannot provide in identifying patient treatment goals," claimed the commentary authors.
While both studies demonstrate wide use of the POLST form in Oregon, the study authors explain the data also shows there is room for improvement to the program. For instance, more formalized education for EMTs and long term care providers is needed and patients should be better informed about methods for ensuring their POLST forms are followed.
"As a result of these studies, the POLST Task Force has revised the form to provide even greater clarity," explained Susan Tolle, M.D., director of the Center for Ethics in Health Care at OHSU and a co-author of each study. "A growing number of other states are now using the POLST Program and a National Advisory Committee has been established."
"To order new forms or learn more about the POLST program, visit the POLST.org Web site," Tolle suggested.
Journal
Journal of the American Geriatrics Society