The study was done in Oregon, one of two states with an end-of-life planning program called POLST (Physician Orders for Life-Sustaining Treatment).
“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 author.
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 unit.”
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 group.
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 forms.
“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 End-of-Life Care.
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: bit.ly/TAzn5L.)
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.