Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life

Abstract

Importance: Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations.

Objectives: To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life.

Design, setting, and participants: Retrospective cohort study of 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.

Exposures: POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury.

Main outcomes and measures: The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life.

Results: Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]).

Conclusions and relevance: Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

Figure 1.. Identification of Eligible Decedents for Cohort of Chronically Ill Patients Hospitalized Near the End of Life With Preceding POLST

POLST indicates Physician Orders for Life-Sustaining Treatment. ^aThe Washington State POLST order for limited additional interventions allows for use of medical treatment, intravenous fluids, and cardiac monitoring as indicated; no use of intubation or mechanical ventilation (though less invasive airway support [eg, continuous positive airway pressure or bi-level positive airway pressure ventilation] may be used); and transfer to hospital if indicated but avoidance of intensive care if possible.

Figure 2.. Associations Between POLST Order for Medical Interventions and Intensive Care Near the End of Life

EHR indicates electronic health record; POLST, Physician Orders for Life-Sustaining Treatment. ^aAdjusted for age at admission, race/ethnicity, education, log-transformed days from POLST completion to study admission, history of cancer with poor prognosis, history of dementia, and POLST signatory. ^bCompared with patients having full-treatment POLSTs (406/656). ^cCompared with patients having full-treatment POLSTs (279/656).

Figure 3.. Associations Between Patient Characteristics and POLST-Discordant Intensive Care

POLST indicates Physician Orders for Life-Sustaining Treatment. ^aComplete cases only. Omitted for continuous exposures. ^bUnadjusted relative risk with multiple imputation of missing data. ^cAdjusted for all exposures presented in the figure, separated by POLST order for medical interventions. ^dRelative risk per year of formal education. ^eThe Washington State POLST specifies that the POLST should always be signed by the patient unless the patient is “decisionally incapacitated,” in which case a legal surrogate may sign the POLST. ^fRelative risk per doubling of days from POLST signature to date of admission (ie, log base 2).