It's a common scenario for hospitalists: A very sick elderly patient requests full treatment in the event of a medical emergency at admission, but you suspect he or she wouldn't survive cardiopulmonary resuscitation (CPR). How do you sensitively convey that to the patient and family in the brief time you have with them before discharge?
In a recent study, physicians characterized critical care provided to about 11% of patients in the ICU as futile. Researchers tracked the outcomes for those patients and painted a dismal picture: Two-thirds died during their hospitalization, while 85% died within 6 months. Those who survived treatments perceived as futile often were dependent on breathing machines or had severe permanent neurological damage. The study appeared in the Sept. 13, 2013 JAMA Internal Medicine.
One solution to this problem may be better use of Physician Orders for Life-Sustaining Treatment (POLST), a form that translates the end-of-life preferences of patients with serious, progressive illness into actionable medical orders.
According to experts, a key to implementing POLSTs and avoiding futile care is focusing on the patient's goals for treatment, rather than the treatments themselves.
“The conversation isn't about the document, it's about the patient—what she would want, the likely outcomes and reasonable treatment options,” said Neil Wenger, MD, ACP Member, a co-author of the futile care study, professor of medicine at the University of California Los Angeles and director of the UCLA Health Ethics Center. “And that conversation may then lead to an appropriate POLST form.”
Starting the POLST conversation
POLSTs are only as effective as the communication among the physician, patient and family about treatment options and goals of care, experts say.
“In order to have the right treatment at the right time in the right place, you have to have the conversation at the right time,” said James Mittelberger, MD, MPH, FACP, chief medical officer for Evercare Hospice and Palliative Care, based in Eden Prairie, Minn., and chair of the California State POLST task force. “Often we don't have the right conversation at the right time, and if we do, we don't document it in such a way that choices are acted upon in urgent situations.”
Ideally, these conversations take place over time as the patient's illness progresses, rather than in the hours just before discharge to a nursing facility or hospice, he said. However, in reality hospitalists typically have only a few encounters with the patient and must make the most of a single, brief conversation to create a POLST, if appropriate.
A good way to start is by making sure the patient understands his or her disease and likely prognosis, said Dr. Mittelberger.
“Often, patients have no idea what the trajectory is for heart failure, chronic obstructive pulmonary disease or dementia,” he said. “Once they understand the range of likely outcomes, they have more sense of control.”
Similarly, it's important to make sure patients with advanced illness understand what the various treatment options on the POLST form really mean, said Janice Boughton, MD, FACP, an Idaho-based internist who has experience working with POLSTs in several states. For example, patients who elect full treatment with CPR should know the likely risks, such as broken ribs, punctured lungs, organ failure and—if they survive discharge—long-term disability and reliance on caregivers.
“People who we ask to make these decisions, patients or families, usually don't know what we are really talking about when we ask them to make a decision about resuscitation (‘code status'),” Dr. Boughton wrote in a recent ACP Hospitalist blog post. “Physicians are much less likely than our patients to request resuscitation in the event of cardiac arrest. I think our values are pretty much the same as those of our patients, we just know more about what cardiopulmonary resuscitation and its aftermath really look like.”
Hospitalists also should fully explain the list of possible medical interventions listed on the POLST form so that patients understand what it means to choose full treatment as opposed to comfort measures or limited interventions, Dr. Boughton said.
“The form can be daunting for anyone not health care savvy,” said Dr. Boughton. “I look at the patient's face to see how they are dealing with the questions” and whether they are confused about terms like intubation or advanced airway interventions.
One of the most common errors physicians make when broaching end-of-life discussions is failing to lead up to the question of whether the patient would want to be resuscitated in an emergency, said Susan W. Tolle, MD, FACP, director of the Oregon Health and Science University's Center for Ethics in Health Care, based in Portland, and a founding member of the national POLST program.
“Don't make this a cold conversation coming out of nowhere,” she said. “Start with something that people tend to have a strong opinion about either way, like whether they would want to be on a permanent feeding tube or whether they would want to come back to the hospital and receive intensive care if something happens in the future.”
That's a clear lead-in to asking about what level of care they would want if they return to the hospital, she said. “That way, they have guided you to the question about CPR versus DNR [do not resuscitate].”
Focus on patients' values
Even in a short conversation, a physician can get a sense of a patient's values, said Dr. Tolle. She advised first looking at what is already in the chart, such as an advance directive, and, if no information exists, asking the patient whether she's ever had experiences with the ICU or with making decisions for a loved one at the end of life.
“Build on the previous conversations,” said Dr. Tolle. “You may have a patient who has been very clear about never going to an ICU again or coming back to the hospital. Those are easy conversations to start because the door is already open and you're picking up the thread.”
Talking to a patient about what's most important in his life can be a very rewarding conversation for both patient and physician, said Dr. Mittelberger.
“Ask them what really matters to them—being there for loved ones? Finishing important pieces of work? What are their biggest fears?” he said. “This can be done in just a few minutes of talking with the patient.”
“Make the personal connection first and see where it goes,” said Dr. Boughton. “Then when you do ask the resuscitation status question, you are much more likely to get an answer that is real to that patient and to know in which direction they want to go.”
Listening to how the patient answers questions about wishes and values is extremely helpful to physicians when family members ask for your advice and recommendations for care, said Dr. Mittelberger.
“Physicians need to make recommendations, because it can reduce the anxiety of family members who are making decisions for a relative,” he said. “It's very important for the doctor to say, ‘Based on what I've heard, this is what I recommend doing.’”
Also, nurses and palliative care teams can help lay the foundation for a POLST by talking to patients and families about their illnesses and treatment options and by providing educational materials, such as videos that discuss end-of-life choices.
“Some patients have no clear idea about their illness, haven't sorted out their values, and may have family disagreements,” said Dr. Mittelberger. “They need clarity on these issues, and a hospitalist is wise to use a palliative care team to support optimal practice.”
It's important to recognize that POLST is a living document that should be revisited as the patient's illness progresses, said Dr. Tolle, noting that of the 3,500 POLST forms entered into Oregon's electronic registry each month, 500 of them are revisions.
“A POLST is much more of a process than an event,” she said. “It's a record of medical orders for what the patient wants today.”