In patients with chronic illness who are hospitalized near the end of life, documented treatment orders such as a Physician Orders for Life-Sustaining Treatment (POLST) can be important for identifying and keeping to agreed-upon care goals and avoiding goal-discordant care. A study aimed to identify associations between POLST orders and intensive care measures in decedents with chronic illness, and the results were published in the Journal of the American Medical Association.
The goal of the study was to examine differences in intensive, end-of-life care based on the type of POLST order, as well as to identify potential risk factors for goal-discordant care. Researchers hypothesized that patients with predictable illness trajectories such as cancer or dementia would be more likely to receive care in line with their POLST orders and that older white and non-Hispanic patients who had signed their own POLST would in addition be less likely to receive goal-discordant care.
To determine whether their hypotheses were correct, the researchers conducted a retrospective cohort study of decedents with pre-existing POLSTs who had been hospitalized near the end of life and had died between the beginning of 2010 and the end of 2017. All decedents in the cohort had chronic life-limiting illness, identified as 1 of 9 conditions, which included cancers with poor prognoses, congestive heart failure, dementia, and others. Associations of POLST with intensive care were evaluated in all patients with a POLST. For the purposes of the study, intensive care was defined as admission to the intensive care unit (ICU) and care via mechanical ventilation, vasoactive infusions, new dialysis, or CPR.
Of the 14,370 patients hospitalized during the study period, 1818 had a POLST and were included in the study cohort. The mean age of the cohort was 70.8. A total of 59% of decedents were men and 74% were white or non-Hispanic. Of decedents, 36% had full treatment orders, 42% had limited treatment orders, and 22% had comfort-only orders. ICU admissions were noted in 62% of decedents for full treatment orders, 46% for limited-intervention, and 31% for comfort-only orders. Despite the comfort-only POLST orders issued by patients, 14% of them received 1 or more life-sustaining treatments. However, these patients and patients with limited treatment orders were still much less likely to be admitted to the ICU than patients with full treatment orders. Some variation existed between the conditions of patients and their associated care. Patients with dementia and cancer had a significantly lower risk for POLST-discordant care. Older age was also associated with less risk for discordant care. Patients with traumatic injuries were conversely more likely to receive discordant care.
The results support the theory that patients whose prognoses are less predictable, such as patients with a traumatic injury, are more likely to receive more intense and POLST-discordant care. The researchers found no significant associations between POLST adherence and race/ethnicity, education level, or whether patients had completed and signed their own POLSTs. Overall, the existence of POLSTs limiting treatment led to lower ICU admission and intensive treatment, although a significant percentage of patients issuing them still received discordant care.
The study does have several limitations, such the fact that all decedents were hospitalized near the end of life and in 2 hospitals, the inclusion of only patients who did not survive their illness after the hospitalization, and possible limits due to data from death certificates possible being misclassified.
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. 2020;323(10):950-960. doi:10.1001/jama.2019.22523