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End of Life

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

Educational Objective
To understand the use of Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations for emergency care.
1 Credit CME
JAMA
March 10, 2020
Original Investigation
Robert Y. Lee, MD, MS1,2;
Lyndia C. Brumback, PhD1,3;
Seelwan Sathitratanacheewin, MD1,4;
William B. Lober, MD, MS1,5,6;
Matthew E. Modes, MD, MPP1,2;
Ylinne T. Lynch, MD2;
Corey I. Ambrose, BSc7;
James Sibley, BS1,5,6;
Kelly C. Vranas, MD8,9;
Donald R. Sullivan, MD, MA, MCR8,9;
Ruth A. Engelberg, PhD1,2;
J. Randall Curtis, MD, MPH1,2,5,10;
Erin K. Kross, MD1,2
Author Affiliations
  • 1Cambia Palliative Care Center of Excellence, University of Washington, Seattle
  • 2Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
  • 3Department of Biostatistics, University of Washington, Seattle
  • 4Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  • 5Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
  • 6Department of Bioinformatics and Medical Education, University of Washington, Seattle
  • 7School of Medicine, University of Washington, Seattle
  • 8Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland
  • 9Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
  • 10Department of Bioethics and Humanities, University of Washington, Seattle
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Conference Presentation: Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life
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Key Points

Question  For patients with treatment-limiting Physician Orders for Life-Sustaining Treatment (POLST) hospitalized near the end of life, how often is their inpatient care consistent with POLST-ordered limitations?

Findings  In this retrospective cohort study of 1818 decedents with POLSTs who were hospitalized within 6 months of death, rates of intensive care unit (ICU) admission differed significantly by POLST order for medical interventions (31% for those who indicated “comfort measures only,” 46% for those who indicated “limited additional interventions,” and 62% for those who indicated “full treatment”).

Meaning  For patients hospitalized near the end of life, treatment-limiting POLSTs were associated with significantly lower rates of ICU admission compared with full-treatment POLSTs, although many patients with treatment-limiting POLSTs received care that was potentially discordant with their POLST.

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.

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Critical Care Medicine Law and Medicine End of Life Ethics
Article Information

Corresponding Author: Robert Y. Lee, MD, MS, Division of Pulmonary, Critical Care, and Sleep Medicine, Cambia Palliative Care Center of Excellence, Harborview Medical Center, University of Washington, 325 9th Ave, Campus Box 359762, Seattle, WA 98104 (rlee06@uw.edu).

Accepted for Publication: January 20, 2020.

Published Online: February 16, 2020. doi:10.1001/jama.2019.22523

Author Contributions: Drs Lee and Kross had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lee, Brumback, Sathitratanacheewin, Lober, Engelberg, Curtis, Kross.

Acquisition, analysis, or interpretation of data: Lee, Brumback, Sathitratanacheewin, Modes, Lynch, Ambrose, Sibley, Vranas, Sullivan, Engelberg, Curtis, Kross.

Drafting of the manuscript: Lee, Sathitratanacheewin, Engelberg.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lee, Sathitratanacheewin, Engelberg.

Obtained funding: Lee, Sathitratanacheewin, Curtis.

Administrative, technical, or material support: Sathitratanacheewin, Lober, Modes, Lynch, Sibley, Engelberg.

Supervision: Brumback, Curtis, Kross.

Conflict of Interest Disclosures: Dr Lee reported receiving grants from the National Institutes of Health (NIH). Dr Brumback reported receiving grants from the NIH. Dr Sathitratanacheewin reported receiving a grant from the Prince Mahidol Youth Program Award. Dr Modes reported receiving grants from the NIH. Dr Lynch reported receiving grants from the NIH. Dr Vranas reported receiving grants from the NIH, the Oregon Health & Science University Medical Research Foundation, and the Collins Medical Trust. Dr Sullivan reported receiving grants from the NIH, the Oregon Health & Science University Medical Research Foundation, the American Lung Association, the American Thoracic Society, the Borchard Foundation, and the Knight Cancer Institute. Dr Engelberg reported receiving grants from the NIH, the Cambia Health Foundation (funding from which supports Drs Brumback and Lober and Mr Sibley), the National Palliative Care Research Center, the Gordon and Betty Moore Foundation, the Stupski Foundation, and the Cystic Fibrosis Foundation. Dr Curtis reported receiving grants from the NIH, the Cambia Health Foundation (funding from which supports Drs Brumback and Lober and Mr Sibley), and the National Palliative Care Research Center. Dr Kross reported receiving grants from the NIH, the American Lung Association, and the American Thoracic Society. No other disclosures were reported.

Funding/Support: This study was supported by the National Institutes of Health, Cambia Health Foundation, and UW Medicine. Dr Lee was supported by an F32 award (HL142211) and a K12 award in implementation science (HL137940); Drs Lee and Modes, by a palliative care T32 training fellowship (HL125195); and Drs Modes and Lynch, by a pulmonary/critical care T32 training fellowship (HL007287), all from the National Heart, Lung, and Blood Institute (NHLBI). Dr Sathitratanacheewin was supported by the Prince Mahidol Youth Program Award, Bangkok, Thailand. Dr Vranas was supported by a K12 award (HL133115) jointly funded by the NHLBI and the National Institute of Mental Health. Infrastructure and chart abstraction support was provided by the University of Washington Institute of Translational Health Sciences (ITHS), which is funded by the National Center for Advancing Translational Sciences through the Clinical and Translational Science Awards (CTSA) Program (UL1 TR002319).

Role of the Funder/Sponsor: The National Institutes of Health, Cambia Health Foundation, and UW Medicine had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: Presented at the Society of Critical Care Medicine 49th Critical Care Congress; February 16, 2020; Orlando, Florida.

Additional Contributions: We acknowledge Lauren Bartlett, BS, Michael Donahue, BS, and Barbara Burke, BS (ITHS), as well as Ross Burnside (Cambia Palliative Care Center of Excellence), for their assistance in digitizing POLST orders. The investigators provided financial compensation via a standard contract for research coordination support services to ITHS for Ms Bartlett, Mr Donahue, and Ms Burke’s work. Mr Burnside received no financial compensation for his contributions.

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