Physician orders for life-sustaining treatment (POLST): Outcomes in a PACEprogram

OBJECTIVES: To evaluate whether terminal care was consistent with Physician Orders for Life-Sustaining Treatment (POLST), a preprinted and signed doct or's order specifying treatment instructions in the event of serious illnes s for CPR, levels of medical intervention, antibiotics, IV fluids, and feed ing tubes. DESIGN: Retrospective chart review. SETTING: ElderPlace, a Program of All-Inclusive Care for the Elderly (PACE) site in Portland, Oregon. PARTICIPANTS: All ElderPlace participants who died in 1997 were eligible (n =58). Reasons for exclusion were no POLST (1), missing POLST (1), and insu fficient documentation of care (2). MEASUREMENTS: POLST instructions for each participant and whether or not ea ch of the treatments addressed by the POLST was administered in the final 2 weeks of life. RESULTS: The POLST specified "do not resuscitate" for 50 participants (93%) ; CPR use was consistent with these instructions for 49 participants (91%). "Comfort care" was the designated level of medical intervention in 13 case s, "limited interventions" in 18, "advanced interventions;" in 18, and "ful l interventions" in 5. Interventions administered were at the level specifi ed in 25 cases (46%); at a less invasive level in 18 (33%), and at a more i nvasive level in 11 (20%). Antibiotic administration was consistent with PO LST instructions for 86% of 28 subjects who had infections in the last 2 we eks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for TV fluids and 94% for feeding tubes. CONCLUSIONS: POLST completion in ElderPlace exceeds reported advance direct ive rates. Care matched POLST instructions for CPR, antibiotics, TV fluids, and feeding tubes more consistently than previously reported for advance d irective instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude tha t the POLST is effective for limiting the use of some life-sustaining inter ventions, but that the factors that lead physicians to deviate from patient s' stated preferences merit further investigation.