BACKGROUND: Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty.
METHODS: We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life).
RESULTS: Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes.
CONCLUSION: We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
| Discipline Area | Score |
|---|---|
| Nurse |  |
| Physician |  |
Nurse rater
This is not my direct field but I find the POLST acronym (and most acronyms) confusing. I'm still not really clear exactly what these orders would look like.
Nurse rater
I agree with the authors' suggestion that pragmatic investigations may be used to inform gaps in knowledge that are contextually based, and therefore inform 'when, where and how POLST might be most effective'. Such study methods are also likely to provide insight into the complex nature of POLST and support patient-and family-focused care.
Nurse rater
The questions identified for future POLST research are important for healthcare practitioners and patient care quality.
Nurse rater
This review, like others, has indicated that in acute care settings patient's wishes about the type of care they receive are more likely to be ignored.
Nurse rater
As a medical oncology nurse/palliative care nurse, I find this article supports that if POLST or 'Goals of Care' underpin each admission and timepoint for a patient, then the patient is somewhat protected from ineffective intensive treatment and/or admission, and can assist in patients choice of place of death.
Physician rater
It is highly important to be able to clearly understand the different distinctions of care that people may want. Unfortunately, many care providers think DNR/DNI means comfort measures only; not only is this an incorrect assumption, but it also means that it becomes **much** harder to convince the chronically ill who would fail to benefit from CPR to accept anything other than full code. Data such as this emphasizes the critical need to address these knowledge gaps so that we do not increase suffering in the future.
Physician rater
This is a review of mostly observational studies of a form particular to the United States. It would be hard to compare to similar attempts to avoid overly aggressive and futile end of life care in other countries.
Dr. Ewa Kostrzewa-Zabłocka (10/31/2021 4:27 PM)
Interesting article that requires additional research on the use of POLST in the period of illness.
, McMaster University