POLST Research: The Quality of POLST Completion in Two States

Alvin Moss, MD, Dana Zive, MPH, Evan Falkenstine, and Courtney Dunithan, MSW, authored a Brief Report recently published in JAMDA, The Journal of Post Acute and Long-Term Care Medicine. The study, The Quality of POLST Completion to Guide Treatment: a 2-State Study, analyzed data from two state POLST Registries: the Oregon POLST Registry and the West Virginia e-Directive Registry.

The study was intended to address the concerns highlighted by Clemency and colleagues in their paper published earlier this year, in which they noted that health care professionals may be confused by incomplete or poorly filled out MOLST Forms. POLST is called MOLST (Medical Order for Life-Sustaining Treatment) in New York, where the study by Clemency et al. was conducted on a small sample of 100 patients treated at one emergency department. There, they found that 69% of the MOLST Forms contained incomplete orders for the level of medical intervention (comfort measures, limited additional interventions, or no limitations on interventions), and that 14% were contradictory, including orders for cardiopulmonary resuscitation (CPR) in combination with comfort measures or limited intervention.

The study by Moss and colleagues was aimed at further investigating the quality of POLST Forms, examining larger data sets for POLST Form completeness and contradictory orders.

The option for Cardiopulmonary Resuscitation (CPR) vs. DNR or Do Not Attempt CPR, is often termed Section A, which is a most essential portion of the form. The next selection of choices, Section B, indicates the level of medical intervention (from least medical intervention, also known as Comfort Care only; through intermediate, or limited, additional interventions; to the highest level of medical intervention, or no limitations), also considered a very critical part of the form, since it guides medical personnel in cases in which the patient is not in cardiopulmonary distress.

Contradictory orders had to be defined for this study, and it was noted that the definitions varied by state POLST policy:

In West Virginia, there were 2 sets of orders that were considered contradictory: an order for CPR in section A with an order for comfort measures in section B; and an order for CPR in section A with an order for limited additional interventions in section B. In Oregon, CPR with comfort measures is considered contradictory, whereas CPR with limited additional interventions is not.”

Results showed low numbers of incomplete and/or contradictory POLST Forms in either state registry:

More than 95% of forms in the Oregon and West Virginia registries were complete in sections A and B. Incomplete orders were almost always in section B. In both states, less than 10% of forms contained inconsistent or contradictory orders (Table 1).

The study authors examined more than 10,000 POLST Forms from tow geographically distinct states, finding more than 95% of them complete. Fewer than 5% had contradictory orders. The authors also discussed the importance of POLST training for health care professionals, to help ensure that POLST Forms are properly filled out (without any contradicting orders). In conclusion, the authors suggest this study demonstrates what results are possible from a statewide POLST Program, and that further research in other regions of the country would be informative.

Source article: Moss, AH, DM Zive, EC Falkenstine, and C Dunithan (2017). The Quality of POLST Completion to Guide Treatment: A 2-State Study. JAMDA. (Online ahead of print publication.)