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Table. Probability of Physician Orders for Life-Sustaining Treatment
Table. Probability of Physician Orders for Life-Sustaining Treatment
1.
Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program.  J Am Geriatr Soc. 2010;58(7):1241-1248PubMedArticle
2.
OHSU Center for Ethics in Health Care.  POLST Paradigm Programs. http://www.polst.org. Accessed October 6, 2011
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McLaughlin M. Exact confidence interval for a proportion. http://www.causascientia.org/math_stat/ProportionCI.html. Accessed November 7, 2011
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President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Washington, DC. Deciding to Forgo Life-Sustaining Treatment. US Government Printing Office; 1983:251
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Beach MC, Morrison RS. The effect of do-not-resuscitate orders on physician decision-making.  J Am Geriatr Soc. 2002;50(12):2057-2061PubMedArticle
6.
Happ MB, Capezuti E, Strumpf NE,  et al.  Advance care planning and end-of-life care for hospitalized nursing home residents.  J Am Geriatr Soc. 2002;50(5):829-835PubMedArticle
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Research Letter
January 4, 2012

POLST Registry Do-Not-Resuscitate Orders and Other Patient Treatment Preferences

Author Affiliations

Author Affiliations: Center for Ethics in Health Care (Drs Fromme and Tolle) and Department of Emergency Medicine (Dr Schmidt and Mss Zive and Olszewski), Oregon Health & Science University, Portland, Oregon.

JAMA. 2012;307(1):34-35. doi:10.1001/jama.2011.1956

To the Editor: The Physician Orders for Life Sustaining Treatment (POLST) form augments traditional methods for advance care planning by translating treatment preferences into medical orders, including for cardiopulmonary resuscitation (CPR), scope of treatment, artificial nutrition by tube, and in some states, antibiotic use. Health professionals complete forms based on conversations with willing patients, primarily with advanced illness or frailty, or surrogates. These orders then guide treatment in any setting. In 3 states, POLST forms were effective in influencing the care that patients received.1 POLST programs currently exist or are in development in 34 states.2 We compared the preferences for other treatments among persons with do-not-resuscitate (DNR) orders and those with attempt CPR orders, using the first year of Oregon POLST Registry data (December 3, 2009, to December 2, 2010).

Methods

POLST includes 2 possible orders for resuscitation: do not attempt CPR (DNR) or attempt CPR. Scope-of-treatment orders consist of limited additional interventions and full treatment, which include hospitalization, and comfort measures only. POLST forms identify patients using name, birth date, sex, and address.

In Oregon, POLST forms are entered into a registry, allowing emergency personnel and hospitals 24-hour access to POLST information when the physical form cannot be located during an emergency. Clinicians in Oregon are required by law to submit forms to the registry unless the patient opts out.

Data were analyzed using IBM SPSS Statistics version 19.0.0 and an online 95% confidence interval calculator.3 The institutional review boards of the Oregon Health & Science University and Oregon State Public Health approved this study and the waiver of informed consent.

Results

At the end of the first year, 25 142 people had active POLST forms in the registry: 85.9% (21 599/25 142) were aged 65 years or older, 61.0% (14 255/23 376) were female, and 40.4% (8014/19 859) resided in a rural area (denominators <25 142 reflect missing data). There were 27.9% (7026/25 142) with an order to attempt CPR and 72.1% (18 116/25 142) with a DNR order. For patients with an attempt CPR order, 75.7% (5218/6895) had orders for full treatment, 21.6% (1492/6895) limited additional interventions, and 2.7% (185/6895) comfort measures only (Table). Of the 18 002 patients with a DNR order, 8929 (49.6%) had orders for comfort measures only and 9073 (50.4%) had orders for either full treatment or limited additional interventions. Thus, half of patients with DNR orders would want to be transported to the hospital if indicated, and half would not unless comfort needs could not be met in their current location.

Among those with POLST DNR orders, the probabilities for having orders for other life-sustaining treatment ranged from 0.101 to 0.557 except for full treatment and long-term tube feeding (Table). Among those with POLST orders to attempt CPR, the probabilities for having orders for other life-sustaining treatments were higher for 6 of the 9 other orders, ranging from 0.021 to 0.739.

Comment

The Oregon POLST Registry allows examination of patient preferences beyond resuscitation status. The number of registry submissions in its first year is noteworthy given Oregon's population of 3.7 million with about 32 000 deaths per year. The main study limitations include having little demographic and no illness information, having data from only a single state, and having no data on patients without POLST forms.

Half of registrants with a DNR order wanted comfort measures only, but half wanted a higher level of treatment. Among persons with a POLST DNR order, a substantial proportion had orders for other life-sustaining treatments. While a DNR order does not mean do not treat, there is substantial evidence that DNR orders do influence care more broadly.4,5 Registry data illustrate why clinicians should not use DNR status to infer more about a patient's wishes. Focus on documenting code status may distract from more important issues,6 and resuscitation may not be the best question for patients with advanced illness and frailty. POLST orders for scope of treatment may be more useful because they allow patients to designate treatment preferences before a cardiopulmonary arrest.

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Article Information

Corresponding Author: Erik K. Fromme, MD, Center for Ethics in Health Care, Oregon Health & Science University, UHN-86, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (frommee@ohsu.edu).

Author Contributions: Dr Fromme has full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Fromme, Schmidt, Tolle.

Acquisition of data: Zive, Olszewski.

Analysis and interpretation of data: Fromme, Schmidt, Tolle.

Drafting of the manuscript: Fromme, Olszewski, Tolle.

Critical revision of the manuscript for important intellectual content: Fromme, Zive, Schmidt, Tolle.

Statistical analysis: Fromme.

Obtained funding: Tolle.

Administrative, technical or material support: Zive, Olszewski.

Study supervision: Schmidt.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Fromme reported grant funding paid to his institution by The Greenwall Foundation; and travel reimbursement from the National Cancer Institute. Dr Tolle reported grant funding paid to her institution by The Greenwall Foundation, The Oregon Community Foundation, The Kinsman Foundation, The Retirement Research Foundation, California HealthCare Foundation, and The Samuel S. Johnson Foundation; and travel reimbursement from the University of Chicago. No other disclosures were reported.

Funding/Support: The Greenwall Foundation funded the initial development of the Oregon POLST Registry. Dr Fromme was supported by a Cancer Prevention Control, Behavioral, and Population Sciences Career Development Award K07CA109511 from the National Cancer Institute.

Role of the Sponsor: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

References
1.
Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program.  J Am Geriatr Soc. 2010;58(7):1241-1248PubMedArticle
2.
OHSU Center for Ethics in Health Care.  POLST Paradigm Programs. http://www.polst.org. Accessed October 6, 2011
3.
McLaughlin M. Exact confidence interval for a proportion. http://www.causascientia.org/math_stat/ProportionCI.html. Accessed November 7, 2011
4.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Washington, DC. Deciding to Forgo Life-Sustaining Treatment. US Government Printing Office; 1983:251
5.
Beach MC, Morrison RS. The effect of do-not-resuscitate orders on physician decision-making.  J Am Geriatr Soc. 2002;50(12):2057-2061PubMedArticle
6.
Happ MB, Capezuti E, Strumpf NE,  et al.  Advance care planning and end-of-life care for hospitalized nursing home residents.  J Am Geriatr Soc. 2002;50(5):829-835PubMedArticle
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