JAMA Research: POLST and ICU Admission at the End of Life

National POLST perspective

Overview

A recent study and editorial published in JAMA addresses the effect of POLST on ICU care. This well-done study increases our understanding of POLST, examines a previously unexplored question, and raises some important questions. However, like most studies, there are limitations and nuances that are important to note in considering whether it is generalizable to other settings (e.g., non–academic hospitals) or states.

Study limitations

Post-traumatic injury care and POLST

Many of the patients categorized by the study as “POLST-discordant” were admitted to the ICU as a result of unexpected traumatic injury. In fact, POLST conversations, and therefore POLST orders, are not designed to address care preferences in the context of such sudden, unexpected events, but instead the context of a patient’s normal, expected progress, given their diagnosis of a chronic illness.

But, the question of whether POLST should be followed in the case of a sudden traumatic injury is often raised. For example, it isn’t clear or there does not appear to be a consensus on “Should POLST orders be honored after a car crash?” Therefore, we appreciate the opportunity to promote awareness of this issue — and National POLST is working on guidance to inform how POLST should be used in trauma events to help ensure consistency.

POLST is for a very specific patient population

POLST isn’t for everyone; and for those for whom POLST is appropriate, it must be done well to be effective in honoring the patient’s wishes. Simply put, the document is a result of a specialized conversation, for only certain patients, and the POLST form will only be as good as those conversations. To ensure shared, informed decision making takes place, the health care team should be teaching the patient about their diagnosis and its full range implications for prognosis and outcome for any life-sustaining treatments.

We recommend review of the National POLST Intended Population & Guidance for Health Care Professionals as a starting point. Outside these guidelines, POLST will not be likely to serve the patients as intended.

Hospital care can be goal-concordant without being POLST-concordant

If we do not know why life-sustaining treatments were applied to patients, we cannot truly assess whether they were concordant with the patient’s wishes. While POLST is intended to ensure patient wishes are honored, the patient (as long as s/he has capacity) has the right to direct, refuse, and override anything in the POLST, which is only going to represent the decisions made at the time of the last POLST conversation. The concern should be whether the patient’s wishes were honored, not whether the care was congruent with the last POLST that was available. By definition, when a patient is hospitalized, a clinical event has occurred that changes the patient health care status, which means a new POLST should be made to reflect the patient’s decision considering the change in status.

Study summary

Goal and definitions

In their research study “Association of POLST with ICU Admission Among Patients Hospitalized Near the End of Life,” authors Robert  Y. Lee, MD, et al.* sought to answer, “How often is inpatient care inconsistent with POLST-ordered limitations?”

*Robert Y. Lee, MD, MS; Lyndia C. Brumback, PhD; Seelwan Sathitratanacheewin, MD; William B. Lober, MD, MS; Matthew E. Modes, MD, MPP; Ylinne T. Lynch, MD; Corey I. Ambrose, BSc; James Sibley, BS; Kelly C. Vranas, MD; Donald R. Sullivan, MD, MA, MCR; Ruth A. Engelberg, PhD; J. Randall Curtis, MD, MPH; and Erin K. Kross, MD.

Study type

A retrospective study, this study used pre-existing data collected from hospital and death records, rather than data collected in a pre-planned manner specifically for the study.

Study population

The retrospective cohort, or pool of individuals whose records provided data for this study, included the 1818 patients who met the all study criteria: chronically ill*, had a pre-existing POLST when admitted to the ICU, died within 6 months of ICU admission, and died between January 1, 2010 and December 31, 2017 in either of 2 hospitals of an academic health care system.

*Chronic life-limiting illness was defined by having any of 9 chronic conditions within the last 2 years of life: cancers with poor prognosis (primary malignancies with poor prognoses, leukemias, and metastatic disease), chronic lung disease, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic renal failure, severe chronic liver disease, diabetes with end-organ damage, and dementia.

Classification of POLST Types

The study compared those with POLST orders for full treatment against those with limited treatments (“Limited additional interventions” on the Washington state POLST form) or comfort-only (“comfort measures only”). The study authors referred to the limited treatment and comfort-only options together as treatment-limiting POLST orders, in contrast to full-treatment orders.

Definition of Intensive Care

Intensive care was defined in two ways:

  1. Admission to the ICU, and
  2. Receipt of any of the 4 following “life-sustaining” treatments:
    1. Mechanical ventilation
    2. Vasoactive infusions (which help restore circulation to the body)
    3. New dialysis or continuous renal replacement therapy
    4. CPR

POLST-discordant care

POLST-discordant intensive care was defined as:

  • For patients with comfort-only POLSTs: Any ICU admission except admissions for symptom management only.
  • For patients with limited interventions POLSTs: Any ICU admission except admissions for symptom management only and admissions solely for delivery of noninvasive ventilation without additional life-sustaining treatments as specified by the Washington State POLST.

Hypotheses

The study authors hypothesized that:

  • Patients with older age, white and non-Hispanic race/ethnicity, higher educational attainment, or who had signed their own POLST would be at lower risk of POLST-discordant care.
  • POLST-concordant care would most likely occur when patient ICU admission was the result of a predictable disease progression vs. an unexpected traumatic event.

Results

Overall numbers of POLST Types

1162 patients who met the study criteria had “treatment-limiting” POLST orders, including

  • 401 with “comfort measures only
  • 761 with “limited additional interventions”

656 patients had POLST orders for “full treatment”

Overall population characteristics

In total, there were 1818 patients who met the study criteria. The average age was 70.8 years, most were male (59%) and most were white (76%) and non-hispanic (98%).

ICU admission

Compared with patients with full-treatment POLSTs, patients with comfort-only or limited-interventions POLSTs were significantly less likely to be admitted to the ICU. The incidence of ICU admission by POLST order was least (31%) for those with comfort-only orders, intermediate (46%) for those with limited-interventions orders, and highest (62%) for those with full-treatment orders. These differences were highly statistically significant (p<.001).

POLST-discordant ICU care

Only 1% of the ICU admissions for patients with treatment-limiting POLST orders were for the sole purpose of managing the patient’s comfort or symptom management, and only 4% of the ICU admissions were for the purpose of noninvasive ventilation (without receiving other life-sustaining treatments). Thus, as one might expect, the incidence of POLST-discordant care was much higher, 30% in the comfort-only group, and 41% in the limited interventions group.

Potential risk factors according to medical history

Patients with a history of cancer were least likely to receive POLST-discordant care compared to patients without cancer. Likewise, patients with dementia were also significantly less likely to receive POLST-discordant care. Patients admitted for traumatic injury were the most likely to receive POLST-discordant care.

Other risk factors

Older age was associated with significantly less POLST-discordant care. Factors that were not correlated with different outcome with regard to POLST-discordant care included: patient race or ethnicity, whether the patient or a surrogate signed on behalf of the patient, or how recently the POLST form was completed.

Traumatic injury as reason for ICU admission

Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care compared patients admitted for other reasons, regardless of their POLST orders (highly statistically significant differences).

Discussion

Treatment-limiting POLST orders reduce ICU admissions

Overall, patients with POLST orders for either limited interventions or comfort-only care were not as likely to be admitted to the ICU compared to patients with POLST orders for full treatment. This provides evidence that POLST orders are correlated with the honoring of patient wishes. Nevertheless, still 38% of patients with treatment-limiting POLSTs in this study were admitted to the ICU, and 18% received life-sustaining treatments (mechanical ventilation, vasoactive infusions, dialysis or CPR).

POLST-discordant may not mean goal-discordant

The study authors pointed out that POLST-discordant care is not necessarily the same as goal-discordant, or inappropriate, care. Context matters, or as the study authors say, “In the setting of acute illness, patients, surrogates, and clinicians may encounter circumstances that ethically compel a different treatment course than that outlined by a previously completed POLST” and “many patients with treatment limitations are willing to grant leeway to future decision-makers.”

Further comments

POLST is for seriously ill patients

Patients who are appropriate for POLST have advanced chronic illness (which can include frailty) that increases their likelihood for a life-threatening clinical event. As such, POLST orders are intended to consider their baseline health, which is, by definition, significantly weaker than that of a healthy person, to the extent that routine “standard of care” life-sustaining treatments are likely not only to fail but cause harm in many cases.

POLST orders do, and should consider context

Thus, as mentioned by Truog and Fried in the same issue of JAMA, POLST is not necessarily intended to address medical care in response to unexpected traumatic injury. POLST is intended to guide care towards the end of life along an expected trajectory due to chronic illness. As such, “POLST-discordant” care, as examined in this study, may actually be appropriate and consistent with patient goals, as the authors suggest. A further refinement of POLST may require careful consideration of the circumstances for which it is appropriate to apply the POLST medical orders. Health care professionals, including POLST leaders, do not agree that POLST should be considered “emergency medical orders,” and it has been commonly understood that POLST should be suspended for certain circumstances such as surgery.

References

    • Lee RY, Brumback LC, Sathitratanacheewin S, et al. Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life. JAMA. Published online February 16, 2020. doi:10.1001/jama.2019.22523
    • Truog RD, Fried TR. Physician Orders for Life-Sustaining Treatment and Limiting Overtreatment at the End of Life. JAMA. Published online February 16, 2020. doi:10.1001/jama.2019.22522