The majority of end-of-life forms for elderly
patients in the study were incomplete
Newswise, October 3, 2016. – In
recent years, Physicians’ Orders for Life Sustaining Treatments (POLST) forms
have been seen as an important way to honor the end-of-life wishes of frail
elderly or terminally ill patients who cannot speak for themselves.
But while the goal of filling out
POLST forms is to let providers know patients’ preferences regarding
life-sustaining treatments, the information they contain is often ambiguous, a
new University at Buffalo study has found.
Published online in the Journal of the American Medical Directors Association, the study is called “Decisions by Default: Incomplete and Contradictory POLST in Emergency Care.”
“We called it ‘Decisions by Default’
to make patients aware that if they don’t make a decision about a specific
life-sustaining treatment, then in an emergency, they will most likely get the
most aggressive treatment available,” said Brian Clemency, DO, associate
professor in the Department of Emergency Medicine in the Jacobs School of
Medicine and Biomedical Sciences at UB and first author on the paper. He also
is a physician with UBMD Emergency Medicine.
Deborah P. Waldrop, PhD, professor in the UB School of Social Work and a nationally- recognized expert on palliative care, is senior author.
The study was conducted in the busy Emergency Department of Erie County Medical Center (ECMC), a partner hospital of the Jacobs School of Medicine and Biomedical Sciences, where Clemency is an emergency medicine attending physician.
“In emergency medicine, we are
trained to do everything we can to prolong life,” Clemency said.
“The goal of this paper is to help
us as emergency medicine physicians honor our patients’ wishes as much as
possible.”
Strictly speaking, the study’s focus was not on the patients themselves, but on the forms that had been completed before their emergency. In New York State, the forms are called Medical Orders for Life Sustaining Treatment or MOLST forms.
One hundred MOLST forms were
collected from patients arriving at the emergency department.
Items included on the form cover
whether or not patients requested cardiopulmonary resuscitation (CPR), do not
resuscitate (DNR) orders, intubation, hospitalization, intravenous fluids,
feeding tubes and antibiotics.
Incomplete forms
Of the 100 forms collected, 69
percent were incomplete with at least one section left blank. That may compel
emergency medicine providers to perform interventions the patient would not
have wanted.
“We want to do what the patient
wants,” explained Clemency, “but if you don’t tell us what you want, we’re
forced to assume you want ‘everything’ done.”
Waldrop, who has spent her career working to provide families dealing with end-of-life issues with better options, says that the research demonstrates a need for greater training among primary care providers.
“Primary care providers are having
these difficult conversations with their patients,” said Waldrop.
“More education and training are
needed to help them be comfortable guiding people with serious illnesses to
effectively communicate their wishes about life-sustaining treatment.”
That means going over any
inconsistencies in the patients’ responses, Clemency said.
For example, if a patient says they don’t want
any life-saving interventions but they do want a breathing tube inserted,
Clemency said that that discrepancy may reflect a lack of understanding on the
part of the patient and should be questioned by the physician.
“I think the doctor’s job is to
guide the patient through it and ask them about the implications of their
decisions,” said Clemency.
Waldrop noted that the forms about
life-sustaining treatment and the conversations about them are a major step
toward improving end-of-life care for patients, but there is room for
improvement.
“This research shows that to be
effective in reflecting patients’ wishes, these forms need to be filled out
completely and without contradictory orders after an informed conversation
between a primary care provider and the patient,” she said.
Improving communication
“Our hope is that this paper will improve communication between patients and providers, better informing the end-users, the emergency medicine doctors who typically meet these patients when they arrive at the emergency department at 3 a.m.,” Clemency added.
And it isn’t only the emergency
physicians who need more clarity, he noted. Families need it too.
“You already have many stressors
when an elderly parent is ill,” Clemency said, “but if the parents’ wishes
aren’t clearly articulated, you might have multiple children, all of whom have
the best of intentions, each of whom has a different understanding of what that
parent wanted.
“Patients and their families can
only benefit when the patients’ wishes are clearly articulated.”
UB co-authors are Jeanne M. Basior,
MD, associate professor and Heather A. Lindstrom, PhD, assistant professor, both
in the Department of Emergency Medicine. Colleen Clemency Cordes, PhD, of
Arizona State University also is a co-author.
