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Analysis

Are ICU Patients' End-of-Life Plans Being Ignored?

By MedPage Today  
   February 17, 2020

Study: More than a third who asked for limited treatment still got intensive care.

This article was first published on Saturday, February 16, 2020 in MedPage Today.

By Salynn Boyles, Contributing Writer

ORLANDO -- Among patients with chronic illnesses nearing the end of life who had physician orders to limit treatment, more than one in three received ICU care that appeared inconsistent with their written wishes, a researcher reported here.

In the retrospective cohort study, 18% of patients hospitalized within 6 months of death whose Physician Orders for Life-Sustaining Treatment (POLST) requested "limited additional interventions" or "comfort measures only" received POLST-discordant life-sustaining treatments, according to Robert Y. Lee, MD, of the University of Washington in Seattle.

And 38% of patients with POLST received intensive care that was potentially discordant with their stated wishes, Lee reported at the Society of Critical Care Medicine (SCCM) congress, and simultaneously in JAMA.

However, treatment-limiting POLSTs were associated with significantly lower rates of ICU admission compared with full-treatment POLSTs in the retrospective analysis of outcomes among 1,818 deceased patients with POLSTs.

Lee told MedPage Today that while POLSTs have been shown to give much needed guidance to emergency medical services (EMS) personnel, "once you get to the hospital it is a little less clear from the evidence if POLST orders are having an impact."

Still, he added that it was reassuring that treatment-limiting POLSTs appeared to reduce unwanted ICU admissions among gravely ill patients.

But understanding why so many patients with treatment-limiting POLSTs received seemingly discordant care is more complicated, he stated.

"Our study was not designed to say whether the care these patients received was appropriate or inappropriate, or whether they requested the care they got," he explained. "The patients or a family member may have changed their minds, or they may not have envisioned the scenario that brought them to the ICU."

Newly installed SCCM President Lewis J. Kaplan, MD, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told MedPage Today that "I have absolute faith that doctors aren't intentionally ignoring their patient's wishes."

But "There is a great deal of nuance here," he said. "Say a patient with a [life-limiting] chronic disease ruptures a spleen or fractures a rib. That patient may be very happy to be on a ventilator, because they will recover."

The study examined the association between POLST order and ICU admission during the last hospitalization of before death among patients with POLSTs (mean age 70.8m, 41% women). A composite of life-sustaining treatments, including mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation, was a secondary outcome.

A total of 401 patients (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment.

Lee and colleagues reported that 31% (95% CI 26%-35%) of patients with comfort-only orders were admitted to ICUs versus 46% (95% CI 42%-49%) with limited-intervention orders and 62% (95% CI 58%-66%) with full-treatment orders.

Also, one or more life-sustaining treatments were delivered to 14% (95% CI 11%-17%) of patients with comfort-only orders and to 20% (95% CI 17%-23%) of patients with limited-intervention orders.

Compared with patients with full-treatment POLSTs, patients who had the comfort-only and limited-intervention POLSTs were significantly less likely to receive ICU admission:

  • Comfort only: 123/401 (31%) vs 406/656 (62%), adjusted relative risk 0.53 (95% CI 0.45-0.62)
     
  • Limited interventions: 349/761 (46%) vs 406/656 (62%), aRR 0.79 (95% CI 0.71-0.87)

The authors also reported that patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer:

  • Comfort only: 41/181 (23%) vs 80/220 (36%), aRR 0.60 (95% CI 0.43-0.85)
     
  • Limited interventions: 100/321 (31%) vs 215/440 (49%), aRR 0.63 (95% CI 0.51-0.78)

In addition, dementia patients who had comfort-only orders received less POLST-discordant care than those without dementia (23/111 or 21% vs 98/290 or 34%, aRR 0.44, 95% CI 0.29-0.67).

And patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care:

  • Comfort only: 29/64 (45%) vs 92/337 (27%), aRR 1.52 (95% CI 1.08-2.14)
     
  • Limited interventions: 51/91 (56%) vs 264/670 (39%), aRR 1.36 (95% CI 1.09-1.68)

Among patients with comfort-only and limited-intervention POLSTs, 38% (95% CI 35%-40%) received POLST-discordant care, according to Lee's group.

Old age was associated with significantly less POLST-discordant care in patients with orders directing limited interventions (aRR 0.93 per 10 years, 95% CI 0.88-1.00), they found.

A study limitation was that enrolled patients with POLSTs were hospitalized near the end of life so the findings do not apply to patients with POLSTs who are not hospitalized near the end of life. "Therefore, the results of this study may overestimate the incidence of POLST-discordant care among all patients with POLSTs," Lee and colleagues cautioned.

In an accompanying editorial, Robert Truog, MD, of the Center for Bioethics at Harvard Medical School in Boston, and Terri Fried, MD, of Yale School of Medicine in New Haven, Connecticut, wrote that while it is not clear if the seemingly discordant care identified in the study was actually consistent with the patients' wishes at the time of care, the findings provide "a strong signal that many patients received overtreatment at the end of life, defined either as treatment that is unwanted or treatment that is unlikely to be beneficial."

They said the study provides important new information about "the relationship between POLSTs and overtreatment of patients who are close to death. These insights will assist clinicians in developing strategies to help ensure that patients hospitalized near the end of life receive only those treatments that are both desired and beneficial."

The study was funded by the NIH, Cambia Health Foundation, and the University of Washington Medicine.

Lee disclosed support from the NIH and the National Heart, Lung, and Blood Institute. Co-authors disclosed support from multiple entities and/or multiple relevant relationships with industry.

Truog disclosed relevant relationships from Sanofi and Covance. Fried disclosed support from the NIH.

Primary Source

JAMA

“Once you get to the hospital it is a little less clear from the evidence if POLST orders are having an impact.”


KEY TAKEAWAYS

Nearly one-in-five patients hospitalized within 6 months of death whose Physician Orders for Life-Sustaining Treatment requested "limited additional interventions" or "comfort measures only" received POLST-discordant life-sustaining treatments.

And 38% of patients with POLST received ICU care that was potentially discordant with their stated wishes.

Ttreatment-limiting POLSTs were associated with significantly lower rates of ICU admission compared with full-treatment POLSTs.


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