July's featured paper is from a team led by Erik Fromme, M.D., associate professor of medicine. It is titled “Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon.” It was published in The Journal of the American Geriatrics Society.

August 5, 2014

Patients, families and health care professionals face important and challenging decisions when contemplating end-of-life care. Deeply personal opinions on the role of health care for those with advanced illness and frailty need to be clearly communicated; while one person may wish for all available medical interventions, another may prefer a less “medicalized” route with a focus on comfort measures at home. 

While important and useful, Advance Directives are not always sufficient to ensure that patient preferences are honored, particularly as patients move between home, nursing facility or hospital.  In order to best ensure that patient wishes are implemented across multiple locations and situations, the Physician Orders for Life-Sustaining Treatment (POLST) program was created in 1991 in Oregon.

Mary Heinricher, Ph.D., assistant dean for basic research, selected this month’s featured paper, “Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon,” because it presents groundbreaking research validating the POLST paradigm. 

“Dr. Fromme and colleagues were able to show that patient’s wishes do have a significant impact on how people are treated – an important landmark for POLST research,” said Dr. Heinricher.

Describing preferences

Originating in Oregon in 1991, the National POLST Paradigm was established when physicians recognized that patient preferences for end-of-life care were not consistently honored, as described by the OHSU Center for Ethics. POLST supplements advance directives for patients with advanced illness by recording their preferences as actionable medical orders. The centerpiece of the POLST program is the bright pink POLST form that includes medical orders regarding resuscitation, artificial nutrition and scope of treatment. The scope of treatment section allows patients to indicate how much treatment they want if they are unable to speak for themselves, with options ranging from full treatment including intensive care to comfort measures only.  If a patient requests comfort measures only, they should not be transported to the hospital unless they cannot be kept comfortable at their current location. 

Previous research has shown that nursing home residents in three states with POLST orders received treatment consistent with their indicated preference 94 percent of the time (Hickman et al J Am Geriatr Soc 2011). 

“We wanted to extend these studies to ask, 'How well does where patients die match their preferences as ordered on the POLST form?'” said Dr. Fromme, a member of the Knight Cancer Institute and lead author on the paper.  Along with colleagues, Dr. Fromme performed a cross-sectional study that examined 58,000 records of natural deaths in Oregon in 2010 to 2011.    

“Of those 58,000 records, nearly 18,000 had a POLST form in the Oregon POLST registry,” said Susan Tolle, M.D. ’77, professor of medicine and director for the OHSU Center for Ethics in Health Care.  “The study compared location of death with POLST orders for the 18,000 people with a form in the registry – we found that only 6.4 percent of patients with comfort measures only orders on their POLST died in a hospital, while 22.4 percent of patients with orders for limited interventions died in a hospital.  44.2 percent of patients with orders for full treatment died in a hospital,” continued Dr. Tolle.

Statewide study

“This study shows that a POLST form matches the treatment patients receive,” said Dr. Heinricher. “Most important, those who specified ‘comfort measures only’ were far less likely to pass in a hospital.” 

Moreover, the pattern of receiving more or less treatment as indicated by patient preference on their POLST forms holds true for all 10 of the most common causes of death in Oregon.

This is the first study that looks at outcomes for an entire state’s population and determined the relationship between POLST orders and the location of death – the POLST research team plan to expand this research study to West Virginia, the only other state to currently implement a statewide POLST registry. 

Closer to home, OHSU has partnered with a software designer, Vynca, to pilot test an electronic POLST app for EPIC.  “We suspect that some completed paper forms are going home with the patient but are not being entered into the electronic medical record and also are not being submitted to the statewide registry,” said Dr. Fromme.  “Through our partnership with Vynca, we continue to lead the national wave of innovation.” 

To learn more about what POLST is, who it is for and more, please visit POLST in Action in Oregon.

• Read the paper
• Read about Dr. Fromme

 

Citation

Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon
J Am Geriatr Soc. 2014 Jul;62(7):1246-51.

Fromme EK, Zive D, Schmidt TA, Cook JN, Tolle SW.

 

More published papers

• Previous School of Medicine Papers of the Month
• Recent OHSU published papers
  

Pictured above from left to right: Jenny Cook, Dr. Fromme, Dr. Tolle. Not pictured: Dana Zive, Terri Schmidt