BY DANIEL GAITAN | daniel@lifemattersmedia.org

The Journal of the American Medical Association has published a perspective highly critical of the Physician Orders for Life-Sustaining Treatment paradigm, a medical order regarding end of life treatment for those with serious illness.

Co-authored by a team of University of Pennsylvania medical researchers, the JAMA article questions the rapid nationwide expansion of POLST, an initiative that aims to help protect terminally ill patients from unwanted medical treatments at the end of life.

They also express concern about the possibility that POLST compromises patient-centered decision-making and the “dearth” of research regarding its impact on end of life care.

‘Problems With Physician Orders For Life-Sustaining Treatment’

According to authors Kendra Moore, Dr. Emily Rubin and Dr. Scott Halpern, the troubling frequency of unwanted medical interventions provided to dying patients gave rise to the “commendable” POLST, more detailed than a conventional living will or advance directive– indicating preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. POLST is primarily for use among patients with life-expectancies of one year or less.

However, authors suggest that POLST may distract from broader goals of promoting informed decision-making and improving the infrastructure necessary for high-quality care delivery to dying patients.

“Although POLST may help avert unwanted medical intervention under a narrow set of circumstances, it may actually curtail patient-centered decision making” among the general population, they write. “Standing physician orders dictating future treatment decisions are appropriate only if preferences are stable over time and across foreseeable clinical contexts.”

Specific medical circumstances and context, they write, are essential to decision-making for most patients not receiving hospice care.

The article recommends that further implementation be accompanied by evaluation of the effects of POLST programs on processes and outcomes of care. Authors also maintain that POLST completion should not be considered a quality metric.

While POLST forms may be amended depending on a patient’s medical status or preference, authors request a “mechanism” to ensure amendments are added when needed.

They also express concern about medical professionals failing to interpret POLST forms accurately or consistently across states.

Until more research is conducted and “problems with POLST” are fixed, researchers caution against the document’s use in different populations.

POLST Response

Susan Tolle, director of the Center for Ethics in Health Care and chair of the Oregon POLST Task Force, maintains that criticism of POLST is a direct result of its increased acceptance and familiarity.

“POLST used to be something that was much more grass-roots and much more within a state,” Tolle told Life Matters Media. “Once the IOM endorsed the POLST paradigm, we changed to something that really was capturing the attention of people at the federal level.”

According to Tolle, concerns about POLST are unfounded. She highlighted a recent study published in the Journal of Pain and Symptom Management finding that more than half of Oregon POLST forms are completed in a patient’s last months of life. That study also found that patients who have had a completed POLST for an extended period of time often change them in the two years preceding death.

Tolle suspects the criticisms were written months before publication, meaning that it is unlikely that authors had access to the latest POLST literature.

“It is interesting that JAMA chose to publish without any review by people who lead POLST programs,” she added. “Some errors would have been corrected.”

Craig Klugman, chair of DePaul University’s Department of Health Sciences, said that the article misrepresents POLST and offers no alternatives.

“The authors phrase it as an all-or-nothing, that you can do POLST or improve end of life care,” he told LMM. “We can do both. POLST is about promoting informed decisions.”

Klugman said that concerns about amending POLST forms are baseless because “you can just rip it up” and complete a new one.

The National POLST Conference takes place in Chicago this week.

POLST Emerges As Standard Medical Order

POLST was first developed in Oregon in the 1990s; 19 states have officially endorsed programs and more than 20 are in the process of developing programs. They vary slightly from state to state.

POLST is divided into basic sections – CPR, medical interventions and artificial nutrition. Medical providers are required to follow patients’ preferences as they are indicated on forms signed by doctors. Ideally, the preparation of a POLST should be accompanied by serious discussion about goals of care between terminally ill patients, their loved ones and medical providers.

For instance, a terminally ill cancer patient may choose to decline resuscitation efforts, but opt for artificial nutrition. An elderly patient suffering severe dementia may opt for comfort care only. A patient receiving hospice care may prefer not to be intubated or to decline antibiotics in all circumstances.

About one million forms have been completed in the U.S., with nearly half coming from Oregon and California.

A 2014 Journal of the American Geriatrics Society study co-authored by Tolle found that patients with POLST forms are highly likely to have their wishes honored.

– Disclosure: Life Matters Media Co-Founders Randi Belisomo and Dr. Mary F. Mulcahy are members of the POLST Illinois Task Force.