POLST Documents Linked to Lower Rates of ICU Admission, Yet Many Patients Still Receive Unwanted Intensive Treatment

A study of patients with Physician Orders for Life-Sustaining Treatment (POLST) documents found that rates of ICU admissions and life-sustaining treatments differ significantly near the end of life.

“Those with full-treatment orders were significantly more likely to receive ICU admission and life-sustaining treatments than those with comfort-only or limited-interventions orders,” the authors write. Yet among patients with treatment-limiting POLST order for medical interventions, “38% were admitted to the ICU and 18% received [life-sustaining treatments],” they note.

Investigators analyzed health data of 1,818 patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system in the state of Washington.

In addition to being stratified by age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury, patients also were stratified by the specifics of their POLST order:

“Comfort measures only” (22%)
“Limited additional interventions” (42%)
“Full treatment” (36%)

During the 8-year study period, 12.7% of patients admitted to hospitals had a POLST that preceded the study hospitalization. Among decedents with any POLST order for medical interventions, 878 (48%) were admitted to the ICU during the study period.

The incidence of ICU admission by POLST order was 123/401 (31%) for those with comfort-only orders, 349/761 (46%) for those with limited-interventions orders, and 406/656 (62%) for those with full-treatment orders.

Intensive Care by POLST Order

Compared with patients who opted for full-treatment POLSTs, patients with comfort-only or limited-intervention POLSTs were significantly less likely to be admitted to the ICU (comfort: adjusted relative risk [aRR], 0.53 [95% CI, 0.45-0.62]; limited: aRR, 0.79 [95% CI, 0.71-0.87]) and were also significantly less likely to receive life-sustaining treatments (comfort: aRR, 0.38 [95% CI, 0.29-0.49]; limited: aRR, 0.53 [95% CI, 0.44-0.63]).
In secondary analyses examining individual life-sustaining treatments, treatment-limiting POLST orders were significantly associated with lower likelihoods of mechanical ventilation, vasoactive infusions, or CPR.

POLST-Discordant Intensive Care

The incidence of POLST-discordant intensive care was 30% (95% CI, 26%-35%) in the comfort-only group and 41% (95% CI, 38%-45%) in the limited- interventions group, a combined incidence of 38% (95% CI, 35%-40%).
The incidence of POLST-discordant delivery of life- sustaining treatments was 14% (95% CI, 11%-17%) in the comfort-only group and 20% (95% CI, 17%-23%) in the limited-interventions group, a combined incidence of 18% (95% CI, 15%-20%).

Given the level of unwanted intensive intervention, hospice care represents an opportunity to provide care that matches patients’ wishes, goals, and values.

Sources: Lee, R.Y., et al. (2020). Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life. JAMA, 323(10), 950. https://doi.org/10.1001/jama.2019.22523