POLST Research: The Oncology Specialist’s Role in POLST Form Completion

cover of an issue of American Journal of Hospice and Palliative MedicineIn this retrospective cohort study, authors Austin Lammers, MD, Dana Zive, MPH, Susan Tolle, MD, and Erik Fromme, MD, analyzed data from Oregon in order to answer the question: “Which specialists hold POLST conversations with cancer patients?”

In the two years from which the study data were taken, 2010 and 2011, 14,979 individuals died of cancer in Oregon. Death certificates which included “malignant neoplasm” as the primary cause of death were matched to individuals in the Oregon POLST Registry.

In Oregon, health care professionals who sign POLST Forms derive from all care settings, including long-term care, health systems, hospitals, clinics, hospice, home-based care, and individuals. All POLST Form signers are required to submit completed POLST Forms to the Oregon POLST Registry unless the patient specifically opts out of the registry.

Key Results

Who signed the POLST Forms?

Within the 2-year retrospective study timeframe, almost 15,000 patients died of cancer. About 41% (6145) of them had POLST Forms in the Oregon POLST Registry.

Of the patients who were in the Oregon POLST Registry, 53.7% of their POLST Forms were signed by primary care physicians and 15.3% by hospice/palliative care specialists, compared to 14.9% by oncologists.

Out of a total of 280 practicing oncology specialists in Oregon in 2010 and 2011, only 135 of them signed POLST Forms relevant to this study. This represents fewer than half of the practicing oncology specialists; more than half (51.8%) of practicing oncology specialists did not sign a POLST Form or did not submit one to the registry. At the same time, 35 (12.5%) oncology specialists completed 10 or more forms in the same time period, indicating that a relatively small number of oncologists engage in POLST conversations frequently.

How did patients fare? Does POLST correlate with the honoring of patient wishes?

For all 6145 POLST-matched decedents, the median time between final POLST Form completion to death was 4.0 weeks. Time between POLST Form and death is regarded as important because an old POLST Form is more likely to be outdated compared to one completed recently. If recent, it is more likely to be a current, and therefore accurate reflection of patient preferences.

Most patients wish to die at home rather than in a medical care facility. POLST Forms are designed to let patients specify a preference for “comfort measures only,” which explicitly states that they do not wish to be transferred to a hospital (except in cases in which it would be necessary to maintain their comfort). So whether POLST Forms result in a difference in location of death for patients is often quantified in order to determine whether POLST makes a difference in honoring a patient’s wishes.

In 2010 and 2011, 18.9%  of cancer patients in Oregon died in an acute care (hospital or emergency department) setting. Analyzing this data with respect to whether patients did or did not have a POLST Form, the study found that 26.8% of patients with no POLST died in a hospital, compared to 4.8% of those with POLST Scope of Treatment orders specifying comfort measures only. Conversely, 52.8% of patients with no POLST Form died at home compared to 66.5% of patients with a comfort measures only order.

Reference: Lammers, AJ, DM Zive, SW Tolle, and EK Fromme (2017). The Oncology Specialist’s Role in POLST Form Completion. American Journal of Hospice & Palliative Medicine. 1-7 (limited access).