Research & References
Please see original sources for further details about contents of these articles, all of which contain information of some type about POLST Paradigm Programs. Summaries are provided for your convenience but are not fully representative of the articles listed below. If you are aware of any articles relevant to the POLST Paradigm that are not included in this annotated bibliography, please forward the reference to polst@ohsu.edu
Original POLST Research
References are presented in chronological order with most recent first:
Hickman SE, Tolle SW, Brummel-Smith K, Carley MM. (2004). Use of the POLST (Physician Orders for Life-Sustaining Treatment) Program in Oregon Nursing Facilities: Beyond Resuscitation Status. Journal of the American Geriatrics Society, 52, 1424-1429.
All licensed nursing facilities in the state of Oregon (n = 151) were surveyed in 2002 to assess use of the POLST Program. The majority (97%) of all facilities participated (3% could not be reached). Of those surveyed, most (71%) reported that they used the POLST form for at least half of their residents and 96% who used the POLST reported that it is used to guide treatment decisions in the facility. Permission was obtained to conduct on-site reviews of records at a sub-sample of 7 facilities identified as users of the POLST Program. POLST forms were present in 92% (429/467) of medical charts reviewed. Treatment orders for adults ages 65+ (n = 397) included do not resuscitate (DNR: 88%), comfort care or limited interventions (88%), no or limited antibiotic use (42%), and no or limited artificial nutrition/hydration (87%). On forms indicating DNR, 77% reflected preferences for more than the lowest level of treatment in at least one other category. On POLST forms indicating orders to resuscitate, 47% reflected preferences for less than the highest level of treatment in at least one other category. The oldest old (aged 85 and up, n = 167) were more likely than the young old (aged 65-74, n = 48) to have orders to limit resuscitation, medical treatment, and artificial nutrition and hydration. Although optional, the majority (71%) of forms were signed by a resident or surrogate.
Meyers JL, Moore C, McGrory A, Sparr J, Ahern M. (2004). Use of the Physician Orders for Life-Sustaining Treatment (POLST) form to honor the wishes of Nursing Home Residents for End of Life Care: Preliminary Results of a Washington State Pilot Project. Journal of Gerontological Nursing, 30, (9), 37-46.
Chart reviews were conducted at nursing facilities in two eastern Washington counties approximately 6 months after implementation of the POLST Program in Washington. POLST forms were found in 21 charts at these facilities. Chart reviews and analysis of interviews with staff and residents/surrogates found evidence that the POLST form accurately conveyed treatment preferences 90% of the time. Most charts contained documentation regarding an informed consent process (76%) and there was evidence that resident’s wishes were honored in a majority of cases (90%). When patients had advance directives in their charts, the POLST form was congruent with the advance directive 100% of the time.
Schmidt TA, Hickman SE, Tolle SW, Brooks HS. (2004). The Physician Orders for Life-Sustaining Treatment (POLST) Program: Oregon Emergency Medical Technicians’ Practical Experiences and Attitudes. Journal of the American Geriatrics Society, 52, 1430- 1434.
In order to better understand the use of the POLST Program, a mail survey was conducted of a random sample of Emergency Medical Technicians (EMTs) with a 55% (572/1050) response rate. Most respondents (72%) had treated at least one patient with a POLST. The majority of patients (71%) with POLST forms were found in long-term care settings. In 45% of cases where a POLST was present, EMTs reported that it changed treatment. Most (74%) of the respondents agreed that the POLST Program provides clear instructions about patient’s preferences and 91% agreed that the POLST Program is useful in determining which treatments to provide when the patient has no pulse and is apneic. Fewer (62%) agreed that the program is useful in determining treatments when the patient has a pulse and is breathing. Findings suggest that EMTs find the POLST Program useful in making treatment decisions for seriously ill patients and often use the form, when present, to change treatment decisions.
Demanelis A, Moss A. (2002). Pilot Study on POST (Physician Orders for Scope of Treatment): Report on POST Form Evaluations. Unpublished Study.
This study examined the completion of the West Virginia POST forms at three West Virginia nursing facilities and one hospice for n = 135 subjects. The POST form is identical to the POLST form on which it was modeled but carries a different name. The majority of forms (64%) indicated DNR status. Comfort care only or limited interventions were requested for 60% of residents. Most forms indicated full treatment with antibiotics (80%). No or limited artificial nutrition and hydration was indicated on 41% of forms (38% requested use of artificial nutrition and hydration and 21% had "other" instructions for this section). The West Virginia Center for End-of-Life Care developed informational brochures and sent a letter to all relevant stakeholders to share the findings of this study and provide additional information about state regulations relating to use of the POST form.
Lee MA, Brummel-Smith K, Meyer J, Drew N, London MR. (2000). Physician Orders for Life-Sustaining Treatment (POLST): Outcomes in a PACE Program. Journal of the American Geriatrics Society, 48, 1219-1225.
A second, retrospective study evaluated the records for the last two weeks of life for enrollees in an Oregon PACE (Program of All-Inclusive Care for the Elderly) site, a program that cares for frail older adults who meet the criteria for nursing facility placement but are maintained at home. It was found that care matched POLST instructions regarding CPR for 91% of participants, antibiotics for 86%, intravenous fluids for 84%, feeding tubes for 94%, and medical interventions for 46%, with more invasive medical interventions given to 20% of participants.
Tolle SW, Tilden VP, Dunn P, Nelson C. (1998). A Prospective Study of the Efficacy of the Physician Orders for Life Sustaining Treatment. Journal of the American Geriatrics Society, 46, (9), 1097-1102.
A sample of n = 180 resident charts at 8 nursing facilities in Oregon were reviewed prospectively over a one-year period. Only the residents whose charts contained POLST forms documenting "do not resuscitate" and "comfort measure only" orders were followed. No participants received unwanted cardiopulmonary resuscitation, intensive care unit care, or ventilator support during the course of the study. Approximately one third had an order for narcotics and a majority (63%) of the residents who died had either PRN or scheduled orders for narcotics. The POLST form orders were consistently followed at this select sample of facilities.
Dunn PM, Schmidt TA, Carley MM, Donius M, Weinstein MA, Dull VT. (1996). A Method to Communicate Patient Preferences About Medically Indicated Life-Sustaining Treatment in the Out-of-Hospital Setting. Journal of the American Geriatrics Society, 44, 785-791.
Focus groups were conducted with health care professionals in Oregon to facilitate the development of the Medical Treatment Coversheet (MTC), the precursor to the POLST form. Next, acute and long-term care providers were provided with hypothetical scenarios and asked to describe their treatment response to each scenario twice: Once without the MTC and once with the MTC. Use of the MTC changed treatment decisions in hypothetical scenarios for 37% of acute care providers and 29% of long-term care providers. The majority of treatment decisions were more appropriate (consistent with patient preferences) with use of the MTC.
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Selected POLST Citations
References are presented in chronological order with most recent first:
Institute for Clinic Systems Improvement (ICSI) Health Care Guideline: Palliative Care
Second Edition, May 2008
Hickman, SE., Sabatino, CP., Moss, AH., Nester Wehrle, J
The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation.
J Law Med Ethics (2008) 36: 119–140
The tables in this manuscript contain a state by state review of each states surrogate laws, advance directives statutes and out of hospital DNR orders. State specific potential legal and regulatory barriers to the implementation of a POLST Paradigm program are identified.
Kellermann A, Lynn J. (2006). Withholding Resuscitation in Prehospital Care. Annals of Internal Medicine. 144 (9), 692-693.
The authors discuss the challenges of decisions to withhold resuscitation outside of the hospital setting. They reference the POLST as a possible tool to facilitate decision making, writing "Perhaps the success of Oregon and other states in encouraging patients with serious chronic illnesses to make plans in advance will inspire nationwide acceptance of a version of POLST. No one with chronic disease that will probably lead to his or her death should leave the doctor’s office or hospital without a discussion and documentation of his or her preferences for life-sustaining treatment, including resuscitation. Our care system should reliably make these decisions available when needed" (p. 693).
Hanson LC, Ersek M. (2006). Meeting Palliative Care Needs in Post-Acute Care Settings "To Help Them Live Until They Die". Journal of American Medical Association. 295 (6), 681-687.
In this article on post-acute palliative care options, the authors identify the POLST as an innovation to improve palliative care outside the hospital setting.
American Heart Association Guidelines for Cardiopulmonary Resusciatation and Emergency Cardiovascular Care Science (2005). Part 8: Interdisciplinary Topics. Circulation. 112 (Suppl I), III-100 - III-108.
A supplemental document developed by the Interdisciplinary Task force from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. As part of a discussion on the ethical issues surrounding resuscitation, the authors note that evidence supports the use of out-of-hospital do-not –attempt-resuscitation orders, noting that "The most studied DNAR form is the Physicians Orders for Life-Sustaining Treatment (POLST) form….We recommend the use of standardized out-of-hospital physician orders for patients who are chronically ill or have a terminal illness" (p. III-102).
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Hickman SE, Hammes BJ, Moss AH, & Tolle SW. (2005). Hope for the Future: Achieving the Original Intent of Advance Directives. The Hastings Center Report Special Report, 35, (6), S26-S30.
Advance directives such as living wills and surrogate appointments were developed as a way for people to maintain control over their medical decision-making in the event of incapacitation. Unfortunately, legalistic traditional advance directives are far less successful than originally hoped for many reasons. In response to these problems, new clinically-based models have been developed and tested with good success. The most widely studies of these programs is the POLST (Physician Orders for Life-Sustaining Treatment) Paradigm, an immediately actionable advance directive that converts patient treatment preferences into medical orders. Key elements of successful advance directives include (1) The development of an individualized plan with a skilled facilitator; (2) Documentation of wishes that are recognized throughout the health care system; (3) appropriately staged timing of discussions; and (4) policies, procedures, and teamwork within each part of the health care system to ensure advance care planning and implementation occurs. Given the initial success of clinical models with these elements, it is reasonable to believe that the original intent of advance directives—to ensure respect for patients’ treatment wishes at the end of life—can and will be more completely realized in the future.
Casarett D, Kapo J, Caplan A. (2005). Appropriate Use of Artificial Nutrition and Hydration – Fundamental Principles and Recommendations. New England Journal of Medicine. 353 (24), 2607-2612.
To over come obstacles to ethical decision making, the authors recommend that "nursing homes and hospitals should develop effective documentation strategies, such as Physicians Orders for Life-Sustaining Treatment forms, which ensure that a patient’s preferences are clearly documented and readily available to guide the patient’s care" (p. 2610).
Cantor MD, Pearlman RA. (2004). Advanced Care Planning in Long-Term Care Facilities. Journal of the American Medical Directors Association. 5(2) (Supplement):S73-S80, March/April 2004.
According to the authors, "The Physician Orders for Life Sustaining Treatment (POLST) program has demonstrated that use of a standardized form can ensure that long-term care patients have their choices about resuscitation and hospitalization respected" (p. S76).
Lorenz KA, Lynn J. (2004). Oregon’s Lessons From Improving Advance Care Planning. Journal of the American Geriatrics Society, 52, 1574-1575.
This editorial was written to accompany the Hickman et al. (2004) and Schmidt et al. (2004) articles. The authors focus on data from a study of the POLST Program in nursing facilities and raise several interesting questions regarding the findings. Systems-based approaches like the POLST Program are identified as a key to improving health care.
Baumrucker SJ. (2004). Physician orders for scope of treatment: An Idea Whose Time Has Come. American Journal of Hospice and Palliative Care, 21,(4), 247-248.
In this sounding board editorial, the author describes the West Virginia POST (Physician Orders for Scope of Treatment) and the advantages of using a medical order form to ensure individual treatment wishes are honored.
Christopher M (Ed.), Bain JW. (2003). Data-Driven Policymaking (an update): Using Statistics to Shape Agendas and Measure Progress. State Initiatives in End-of-Life Care, No. 18.
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Gillick MR. (2003). Adapting Advance Medical Planning for the Nursing Home. Innovations in End-of-Life Care, 5, (3).
Despite the importance of advance care planning for nursing home residents with medical frailty and advanced age, research suggests that rates of advance care are far below optimal in this setting. The author explores current data and discusses what kind of advance planning would be most useful in the nursing home. The POLST program is offered as a successful, systems-based approach model.
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Hickman SE. (2002). Improving Communication Near the End of Life. American Behavioral Science, 46, 252-267.
This review article on communication includes a discussion on the coalition building strategies that led to the development of the Oregon POLST Task Force.
Tolle SW, Tilden VP. (2002). Changing End-of-Life Planning: The Oregon Experience. Journal of Palliative Medicine, 5, (2), 311-317.
Large state-by-state variations exist in location of dying and level of aggressive treatment during the final phase of life. This paper describes Oregon's incremental gains toward improving advance planning for end-of-life care in a state with the lowest rate of in-hospital deaths. Action strategies have required data gathering and reporting, and coalition building with a focus on systems change. Also, public education through the news media has proved to be a vital component of Oregon's process of change. The impact of media coverage is complemented by continuing education for health professionals. Special efforts are still needed to improve access to the Physician's Order for Life-Sustaining Treatment program (POLST) for some rural, minority, and pediatric populations and for persons living at home with a diagnosis other than cancer. However, with enough time, a sustained effort, and a broad coalition of partners, profound change is possible.
Cantor MD. (2000). Improving Advance Care Planning: Lessons From POLST. Journal of the American Geriatrics Society, 48, (10), 1343.
This editorial was written to accompany the Lee et al. (2000) article on the use of the POLST in at PACE setting. The article is critiques and relevant findings from other studies are used to raise questions about the results.
Christopher M. (Ed), Spann, J. (1999). Implementing End-of-Life Treatment Preferences Across Clinical Settings. State Initiatives in End-of-Life Care, No. 3.
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