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. 2020 Feb;75(2):171-180.
doi: 10.1016/j.annemergmed.2019.05.008. Epub 2019 Jun 24.

The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department

Kelly C Vranas  1 , Amber L Lin  2 , Dana Zive  2 , Susan W Tolle  3 , Scott D Halpern  4 , Christopher G Slatore  5 , Craig Newgard  2 , Robert Y Lee  6 , Erin K Kross  6 , Donald R Sullivan  5
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The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department

Kelly C Vranas et al. Ann Emerg Med. 2020 Feb.

Abstract

Study objective: Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED).

Methods: This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment.

Results: A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61).

Conclusion: Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

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Conflict of interest statement

Conflicts of Interest: Ms. Zive received salary support from the Oregon POLST Registry. All other authors have disclosed that they do not have any conflicts of interest.

Figures

Figure 1.
Figure 1.
Study Flow Diagram. *High utilizers were defined as patients with > 10 ED visits during the study period. We excluded patients who had >10 ED visits during the study period, as the majority of these patients presented with recurrent mental health crises or for regular hemodialysis sessions, did not have POLST forms, and were not presenting to the ED with acute medical issues. †Physician Orders for Life-Sustaining Treatment
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References

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