Research by Sandra L. Pedraza, Stacey Culp, Mark Knestrick, Evan Falkenstine, and Alvin H. Moss recently published in the Journal of Oncology Practice examined whether advanced cancer patients were more likely to avoid unwanted aggressive care at the end of life if they had completed Physician Orders for Life-Sustaining Treatment (POLST) Forms rather than Advance Directives (ADs).
The authors explain, “In the literature, aggressive care is described as including hospitalization in the last 90 days of life, intensive care unit admission in the last 30 days of life, death in the hospital, care setting transitions in the last 3 days of life, and either no hospice or hospice enrollment for less than 4 days. Conversely, family caregivers report excellent end-of-life care more often for their loved ones with advanced cancer if they received other than aggressive care.”
The patients in this retrospective study were West Virginians who voluntarily submitted completed ADs and/or POLST forms to the West Virginia e-Directive Registry and died as a result of cancer between January 1, 2011,and February, 4, 2016. Only patients were were at least 18 years old were included in the study. In addition, a date of form completion, and site of death were study inclusion criteria (requirements for the study).
Of the 2,159 patients included in the study, 1,108 (51.3%) had an AD, 756 (35%) had a POLST Form, and 295 (13.7%) had both in the registry. Because the out-of-hospital-death (OHD) and hospice admission outcomes for patients with both forms were significantly better than those for patients who had completed an AD only but were not better than those for patients with POLST alone, statistically speaking, there was no incremental benefit to having both forms. Because of this, the results are presented as outcomes for POLST Forms versus ADs.
POLST Forms were completed an average of 3.0 months before death (range: 0 to 88.4 months). ADs were completed, on average, 8.6 months before death (range: 0 to 275.8 months). Lung cancer was the most frequent cause of death (28.4%), followed by colorectal cancer (8.8%), pancreatic cancer (6.3%), breast cancer (5.9%), and prostate cancer (2.9%); all other cancer types accounted for 47.6% of the deaths.
The authors found that patients with completed POLST Forms compared with patients with completed ADs had a higher rater of OHD: 85.7% (patients with POLST) versus 72.0% (patients with AD), P<0.001. Patients with POLSTs also had a higher rate of hospice admission (49.9% versus 27.0% in patients with ADs, P<0.001). Patients with POLST Forms were 2.33 times more likely than patients with ADs to have an OHD, and 2.69 times more likely to be admitted to hospice (both P<0.001). Finally, the orders included on the POLST Form were shown to matter, as patients with POLST comfort measures and limited additional interventions were more likely to have an OHD than those with POLST full treatment orders (87.5%, 85.0%, and 72.3%, respectively; P<0.003).
In conclusion, it appears that in patients with advanced cancer, advance care planning with the completion of POLST, in comparison to advance care planning with only ADs, results in “greater achievement of two metrics for quality end-of-life care: OHD and hospice admission.” The study authors conclude, “Our study suggests that a goals-of-care discussion with POLST form completion may represent an actionable approach to improve end-of-life care for patients with advanced cancer. Further research is needed to establish whether wider use of this approach by oncologists and others who care for patients with advanced
cancer can reverse the trend toward increasingly aggressive care near the end of life.”
Pedraza S, S Culp, M Knestrick, E Falkenstine, and AH Moss (2017). Association of Physician Orders for Life-Sustaining Treatment (POLST) Form Use With End-of-Life Care Quality Metrics in Patients With Cancer. Journal of Oncology Practice. Published online before print July 20, 2017. DOI: 10.1200/JOP.2017.022566