New Approach Reduces Unwanted Medical Treatments at End of Life

Nursing home patients are less likely to be subjected to unwanted medical interventions or hospitalizations under a program that offers an alternative to simple advance directives, according to a new study.

While advance directives or "living wills" provide general guidance on what type of care a patient would like, they are not consistently followed, in part because they don't give health care professionals explicit instructions for making critical decisions about a patient's care. Studies show they often have little impact on end-of-life decision making.

An alternative has emerged in recent years and has been implemented or is being developed in 32 states: the Physician Orders for Life-Sustaining Treatment (POLST). The POLST uses a standardized medical order form to indicate which types of life-sustaining treatment a seriously ill patient wants or doesn't want if his or her condition worsens.

The POLST form records whether the patient wants to receive CPR, hospitalization, ICU care, antibiotics, artificial nutrition, intubation, mechanical ventilation and other medical interventions. A physician (or a nurse practitioner in some states) reviews and signs the form and it is added to the patient's medical file, moving with the patient and honored across all settings of care. (The POLST program is known by different names in different states. For example, in New York it's Medical Orders for Life-Sustaining Treatment (MOLST), and in West Virginia it's Physicians Orders for Scope of Treatment (POST).)

A new study published in the July 2010 issue of the Journal of the American Geriatrics Society found that people with POLST forms were more likely to receive the treatment they wanted. For example, those who said they primarily wanted relief from pain were 59 percent less likely to receive unwanted treatments than those who had only a "Do Not Resuscitate" order. Meanwhile, patients who requested on their POLST that everything be done to keep them alive were just as likely to receive full treatment as were other patients.

Something like the POLST is particularly welcome in nursing home settings because the common practice is to do everything possible for patients despite the fact that only about 12 percent of nursing home patients want intensive care treatments, according to study co-author Susan Tolle of the Oregon Health & Science University. "There are many health care professionals who welcome this, particularly emergency medical personnel," Tolle said.

Meanwhile, the authors of another recent study conclude that elderly patients dying in hospitals "often receive burdensome care immediately before death that may not match patient preferences." The researchers see a need for improved communication between clinicians and patients or families at the beginning of intensive treatments.

For a Kaiser Health News article about the POLST study, click here.

For more on health care decisions, click here.