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Conflicting Orders in Physician Orders for Life‐Sustaining Treatment Forms
Author(s) -
Lee Robert Y.,
Modes Matthew E.,
Sathitratanacheewin Seelwan,
Engelberg Ruth A.,
Curtis J. Randall,
Kross Erin K.
Publication year - 2020
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/jgs.16828
Subject(s) - medicine , psychological intervention , intensive care , retrospective cohort study , logistic regression , cardiopulmonary resuscitation , odds ratio , medical record , advance care planning , emergency department , health care , emergency medicine , resuscitation , intensive care medicine , palliative care , psychiatry , nursing , economics , economic growth
BACKGROUND/OBJECTIVES Many older persons with chronic illness use Physician Orders for Life‐Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders. DESIGN Retrospective cohort study. SETTING Large academic health system. PARTICIPANTS A total of 3,123 POLST users with chronic life‐limiting illness who died between 2010 and 2015 (mean age = 69.7 years). MEASUREMENTS In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions. RESULTS Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to “attempt CPR” paired with orders for “limited interventions” or “comfort measures only”; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non‐comfort‐only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18–1.36; P < .001). CONCLUSION Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.