For patients with treatment-limiting Physician Orders for Life-Sustaining Treatment
(POLST) hospitalized near the end of life, how often is their inpatient care consistent
with POLST-ordered limitations? In this retrospective cohort study of 1818 decedents
with POLSTs who were hospitalized within 6 months of death, rates of intensive care
unit (ICU) admission differed significantly by POLST order for medical interventions
(31% for those who indicated “comfort measures only,” 46% for those who indicated
“limited additional interventions,” and 62% for those who indicated “full treatment”).
For patients hospitalized near the end of life, treatment-limiting POLSTs were associated
with significantly lower rates of ICU admission compared with full-treatment POLSTs,
although many patients with treatment-limiting POLSTs received care that was potentially
discordant with their POLST. Patients with chronic illness frequently use Physician
Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. To
evaluate the association between POLST order for medical interventions and intensive
care unit (ICU) admission for patients hospitalized near the end of life. Retrospective
cohort study of patients with POLSTs and with chronic illness who died between January
1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death
in a 2-hospital academic health care system. POLST order for medical interventions
(“comfort measures only” vs “limited additional interventions” vs “full treatment”),
age, race/ethnicity, education, days from POLST completion to admission, histories
of cancer or dementia, and admission for traumatic injury. The primary outcome was
the association between POLST order and ICU admission during the last hospitalization
of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments:
mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation.
For evaluating factors associated with POLST-discordant care, the outcome was ICU
admission contrary to POLST order for medical interventions during the last hospitalization
of life. Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%)
had POLST orders for comfort measures only, 761 (42%) had orders for limited additional
interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred
in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%)
with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders.
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-interventions
orders. Compared with patients with full-treatment POLSTs, those with comfort-only
and limited-interventions orders were significantly less likely to receive ICU admission
(comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 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]). Across
patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%)
received POLST-discordant care. 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]). Patients with dementia and comfort-only
orders were significantly less likely to receive POLST-discordant care than those
without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). 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]). In patients
with limited-interventions orders, older age was significantly associated with less
POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Among patients
with POLSTs and with chronic life-limiting illness who were hospitalized within 6
months of death, treatment-limiting POLSTs were significantly associated with lower
rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients
with treatment-limiting POLSTs received intensive care that was potentially discordant
with their POLST. This cohort study uses electronic health record (EHR) data to evaluate
the association between Physician Orders for Life-Sustaining Treatment (POLST) and
intensive care unit (ICU) admission and the incidence of and risk factors for POLST-discordant
intensive care among adult patients hospitalized 6 months or less before death.