The study was done in Oregon, one of two states with an end-of-life
planning program called POLST (Physician Orders for Life-Sustaining
“POLST is not for everyone. Only patients with serious illness or
frailty should have a POLST form,” the program’s website notes.
But for those patients, “POLST records and honors wishes in a way
that (medical professionals understand) and can implement across
settings of care,” said Dr. Susan Tolle, an internist at Oregon
Health and Science University in Portland and the study’s senior
Bright pink POLST forms are medical orders signed by physicians,
nurse practitioners or physician assistants after discussions with
patients about preferred treatment plans.
Tolle’s team studied death records of 58,000 people who died of
natural causes in 2010 and 2011. About 30 percent had copies of
their POLST form in a state-wide registry. The researchers compared
the location of death on death records to POLST patient preferences.
“Although it is probably more important how you die than where you
die, where you die can strongly affect how you die,” they write in
the Journal of the American Geriatrics Society.
POLST forms don’t let patients specify where they prefer to die.
Instead, the forms include three order sets that could impact
location. More than two thirds of patients with POLST forms had
chosen the first option: “prefers no transfer to hospital for
life-sustaining treatments . . . transfer if comfort needs cannot be
met in current location.”
Slightly more than a quarter chose the second option: “transfer to
hospital if indicated . . . generally avoid the intensive care
Only six percent chose full treatment: “transfer to hospital and/or
intensive care unit if indicated.”
One limitation of the study is that for people who died without a
POLST form in the registry, there was no way to know what their
preferences would have been. Also, the results would have been more
reliable if everyone had been randomly assigned to a POLST or no-POLST
Still, the researchers believe, their findings suggest POLST forms
made it more likely that patients’ wishes would be carried out.
For example, among the general population of patients without a
POLST form, 34 percent died in a hospital. But among patients with a
POLST form who said they would prefer comfort-measures only, with no
life-sustaining treatments, only about 6 percent died in a hospital.
Similarly, people whose POLST forms said they wanted full treatment
were more likely to die in the hospital than those without POLST
“This is the first study that shows that patients who do not want to
die in the hospital can have those wishes respected with the POLST
form,” said Dr. Alvin Moss, director of the West Virginia Center for
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West Virginia and Oregon are the only states with mature POLST
programs. Forty-one other states have POLST programs in various
stages of development. (Go here to check your state’s status:
Betty Lou Hutchens, 92, of Lake Oswego, Oregon completed a POLST
after being diagnosed with congestive heart failure. “I was relieved
to know I could think about it ahead of time and write down my
wishes,” she said. Hutchens resides in an assisted-living facility,
where her form is kept at the nursing station. Her wishes to avoid
intensive care were recorded after discussing various end-of-life
scenarios with her health care provider.
“It’s hard to talk to people about the future, about what might
happen to them if you start with nothing,” said Dr. Erik Fromme, a
palliative care specialist and the study’s lead author. “POLST has a
nice way of breaking down different goals and different ways of
approaching the healthcare of a patient with a life-threatening
illness that can enhance the quality of communication.”
The data suggesting these goals will be honored are “jaw dropping,”
according to Dr. Mark Siegler, the Director of the MacLean Center
for Clinical Medical Ethics at the University of Chicago.
“If it turns out that many people don’t want to be in hospitals, and
that POLST forms may be respected and effective in keeping people
out of hospitals that don’t want to be there, this is an incredible
finding,” Siegler said.
He said the POLST program is certain to generate enthusiasm among
patients, physicians and policymakers, as the Dartmouth Atlas of
Health Care reports that hospitalizations during the last two years
of life now account for a third of total Medicare spending. That
spending has not been associated with better outcomes.
“If cost containment goes along with good care and respect for
patient wishes, this is a great way to save money also,” said
Journal of the American Geriatrics Society, online June 9, 2014.
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