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Expanding the Use of Provider Orders for Life-Sustaining Treatment for Patients With Advanced Cancer


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Law and Ethics in Oncology explores the legal and ethical issues oncologists must be aware of in this era of precision medicine and changing healthcare policy, both to protect patients’ rights and to safeguard against potential legal jeopardy.

Patients with advanced cancer often get more aggressive treatment than they want because too few oncologists elicit their end-of-life treatment preferences.1,2 In response to this problem, leading associations, including ASCO3,4 and the Institute of Medicine,5 have called for more advance care planning. Medicare has also recognized the value of advance care planning, expanding reimbursement for the service in 2016.6,7

A key component of advance care planning for some patients is the Provider Orders for Life Sustaining Treatment (POLST) directive, which encourages providers to speak with patients about their end-of-life treatment preferences and creates specific medical orders to be honored during a medical crisis. But POLST remains underutilized by oncologists with their advanced cancer patients. Here, we provide some recommendations on how oncologists should take advantage of POLST to help patients improve their end-of-life care.

Thaddeus Mason Pope, JD, PhD

Thaddeus Mason Pope, JD, PhD

Limitations of Advance Directives

BOTH LAW AND medical practice support a presumption that each patient will receive aggressive interventions to prolong her or his life. The patient may rebut this presumption and decline treatment, even if that choice hastens the patient’s death. But many patients lack the capacity to make health-care decisions at the end of life. For decades, medical and legal experts have looked to the advance care directive as a central mechanism for assuring that incapacitated patients are treated in accordance with their preferences.8 Unfortunately, the advance directive has had only limited success.8

There are several reasons these documents have proven insufficient. First, many patients have not completed an advance directive. Second, most of the advance directives that have been completed are unavailable when needed. Even if both of these hurdles are overcome, there are other obstacles in the way. For example, to implement patient preferences, advance directives must be reduced to medical orders. But advance directives often only appoint a durable power of attorney for health care.1

Even when they contain information about patient preferences, advance directives are often vague or ambiguous. This leaves providers uncertain as to how the instructions apply to the patient’s current clinical circumstances. Take the phrase, “If I am close to death,” often included in advance directives—does that mean within weeks or within hours? And even once orders are written, they do not travel outside the institution.9

“Meant to supplement, not replace, traditional advance directives for patients expected to die within the next year, POLST has several advantages over advance directives.”
— Thaddeus Mason Pope, JD, PhD

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Advantages of POLST Directives

POLST HELPS ADDRESS these problems. Meant to supplement, not replace, traditional advance directives for patients expected to die within the next year, POLST has several advantages over advance directives.8 To begin with, POLST is signed by both the patient (or surrogate) and the clinician (usually a physician, advance nurse practitioner, or physician assistant); there is no need for interpretation and translation; and it is an immediately actionable medical order.

Since POLST is a single-page, standardized form, it is easy to follow. Unlike do-not-resuscitate orders, POLST addresses not just cardiopulmonary resuscitation, but an entire range of life-sustaining interventions, such as feeding tubes and mechanical ventilation. Moreover, POLST is transportable. It is usually a brightly colored, clearly identifiable form that remains in the patient’s chart and travels with the patient from the hospital to nursing home to ambulance and to the patient’s home. POLST is recognized and honored across all these different treatment settings.8

In addition, POLST protects and promotes patient autonomy better than advance directives in at least four ways. First, POLST is usually created with a health-care provider at or near the time when an acute or serious chronic condition develops. Therefore, it addresses the patient’s current situation, not a possible future scenario. Consequently, POLST has a greater chance of being more informed and more relevant to the specific medical situation at hand.

Second, since the POLST form is highly visible, portable, and travels with the patient’s medical records, it is more likely available at the time that a medical decision must be made. Third, since POLST is written in precise medical language on a standardized form, it is better understood by health-care providers. Fourth, since POLST is signed by a provider, it has a greater chance of leading to compliance by other providers.8

ABOUT POLST

  • Variously defined as Provider, Physician, Practitioner, or Professional Orders for Life-Sustaining Treatment, POLST is a paradigm for improving end-of-life care that was first advanced in Oregon in 1991.
  • The POLST form is a standardized, portable, usually brightly colored single-page medical order that describes a patient’s end-of-life care preferences, as documented by a provider.
  • Currently, all 50 U.S. states and Washington, DC, have some type of POLST form, although many of these forms do not meet the national standard established in 2004.
  • For more information about POLST and how it is used in particular states, visit polst.org.

Ensuring Quality of Care

WITH AN ADVANCE directive, patients with progressive cancer have a varying capacity for avoiding unwanted aggressive treatment and receiving palliative care.10 But with a POLST document, these patients are even more likely to avoid unwanted aggressive treatment and to receive timely palliative care.11,12 Because POLST is a signed order, there is a stronger association between POLST and treatment received than between advance directives and treatment received.13 Clinicians can and will follow a POLST directive better than they can follow an advance directive.

Consequently, patients with a POLST document show significant improvements on well-accepted quality-of-care measures, such as rates of out-of-hospital death and hospice enrollment. In one study, the out-of-hospital death rate for patients with POLST was 76%, compared with 57% for those with only advance directives.14 In another study, the out-of-hospital death rate for patients with POLST was 86%, compared with 72% for those with only advance directives.15 Similarly, the hospice rate for patients with POLST was 50%, compared with 27% for those with only advance directives.15 Some innovative POLST forms are associated with even better outcomes on these measures.16

Despite these benefits, there are concerns about POLST forms, including potential problems that can impact patient safety.17 For example, some POLST forms are completed with inconsistencies, contradictions, and missing sections.18 More physician training in filling out the form and completing it online in a patient’s electronic medical record can help prevent such errors.

Perhaps more troubling, several studies show that clinicians sometimes misinterpret the information found in POLST forms,19,20 which can result in some patients being resuscitated against their wishes and others not being resuscitated when they should have been. Supplementing written POLST forms with patient videos may help prevent these errors.21 In the meantime, POLST experts emphasize that even with some completion and miscommunication errors, patient wishes are still more likely to be followed with a POLST document in place than without one.22

Increasing POLST Use

ALTHOUGH ADVANCE care planning and discussions about end-of-life preferences increase the quality of care for patients with cancer, often these important conversations do not occur. This is also an issue for POLST programs.23

“Despite both the demonstrated advantages and the recommendations of professional societies, most oncologists are not using POLST forms in their practice.”
— Thaddeus Mason Pope, JD, PhD

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Despite both the demonstrated advantages and the recommendations of professional societies, most oncologists are not using POLST forms in their practice. One study showed that fewer than 20% of patients with advanced-stage lung cancer had completed a POLST form.24 In another study, 6,145 patients who died of cancer had a POLST form in place, but fewer than 15% of those forms had been signed by an oncologist.25

Indeed, more than half of oncologists have never signed a POLST form. Some research suggests that it may be more appropriate for primary care physicians and palliative care providers to complete and sign POLST forms rather than oncology providers.26 But others conclude that oncologists must play a more “central role” in POLST completion.25

Avoiding Overuse of POLST

ALTHOUGH UNDERUTILIZING POLST may be the primary patient safety problem, overuse is also a concern. Like any clinical tool, improper implementation can present risks. POLST is designed for use with seriously ill or frail patients who are expected to die in the next 1 or 2 years. According to a study examining the problems with POLST, “Standing orders dictating future treatment decisions are appropriate only if preferences are stable over time and across foreseeable clinical contexts.”27 The specificity of the medical orders contained in POLST is justified by the proximity between the patient’s condition and care decisions. Accordingly, while advance directives are typically completed years before death, POLST directives are typically completed just weeks before death.15,28

“Although underutilizing POLST may be the primary patient safety problem, overuse is also a concern.”
— Thaddeus Mason Pope, JD, PhD

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Increasingly, however, clinicians are using POLST with patients who are “too healthy.”29,30 Some of this expanded use is being driven by financial incentives from health-care systems for completing the directive. Granted, using POLST completion as a measured or rewarded outcome may increase the number of forms completed, but they will be of low quality, because they memorialize decisions about a range of premature and out-of-context interventions inappropriate to these patients’ situations.29,30 Patients whom clinicians do not expect to die within the next 2 years should have an advance directive but not a POLST directive, until they become sicker.31

Closing Thoughts

SIGNIFICANT EVIDENCE shows that having a POLST document in place gives patients more control over the treatments they want to receive and allows them to avoid treatments they do not want. To improve patient care and reduce medical errors, oncologists should integrate POLST policies into their goal-of-care conversations with advanced cancer patients. ■

Dr. Pope is Director of the Health Law Institute and Professor of Law at the Mitchell Hamline School of Law in Saint Paul, Minnesota (www.thaddeuspope.com).

Editor’s Note: The Law and Ethics in Oncology column is meant to provide general information about legal topics, not legal advice. The law is complex, varying from state to state, and each factual situation is different. Readers are advised to seek advice from their own attorney.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.

DISCLOSURE: Dr. Pope reported no conflicts of interest.

REFERENCES

1. Narang AK, Wright AA, Nicholas LH: Trends in advance care planning in patients with cancer: Results from a national longitudinal survey. JAMA Oncol 1:601-608, 2015.

2. Keating NL, Huskamp HA, Kouri E, et al: Factors contributing to geographic variation in end-of-life expenditures for cancer patients. Health Aff 37:1136-1143, 2018.

3. ASCO Special Article: Cancer care during the last phase of life. J Clin Oncol 16:1986-1996, 1998.

4. Peppercorn JM, Smith TJ, Helft PR, et al: American Society of Clinical Oncology statement: Toward individualized care for patients with advanced cancer. J Clin Oncol 29:755-760, 2011.

5. Institute of Medicine: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC; National Academies Press; 2014. Available at www. nationalacademies.org/hmd/Reports/2014/Dying-In-America- Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx. Accessed August 17, 2018.

6. Centers for Medicare & Medicaid Services: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016. Federal Register 80 FR 41685, November 15, 2015.

7. Pope TM: Legal briefing: Medicare coverage of advance care planning. J Clin Ethics 26:361-367, 2015.

8. Pope TM: Legal briefing: POLST: Physician orders for life-sustaining treatment. J Clin Ethics 23:353-376, 2012.

9. Pope TM: Clinicians may not administer life-sustaining treatment without consent: Civil, criminal, and disciplinary sanctions. J Health Biomedical Law 9:213-296, 2013.

10. Silveira MJ, Kim SY, Langa KM: Advance directives and outcomes of surrogate decision making before death. N Engl J Med 362:1211-1218, 2010.

11. Hickman SE, Critser R: National standards and state variation in physician orders for life-sustaining treatment forms. J Palliat Med 21:978-986, 2018.

12. Collier J, Kelsberg G, Safranek S: How well do POLST forms assure that patients get the end-of-life care they requested? J Fam Pract 67:249-251, 2018.

13. Fromme EK, Zive D, Schmidt TA, et al: Association between Physician Orders for Life-Sustaining Treatment for scope of treatment and in hospital death in Oregon. J Am Geriatr Soc 62:1246-1251, 2014.

14. Tolle SW, Teno JM: Lessons from Oregon in embracing complexity in end-of-life care. N Engl J Med 376:1078-1082, 2017.

15. Pedraza SL, Culp S, Knestrick M, et al: Association of Physician Orders for Life-Sustaining Treatment form use with end-of-life care quality metrics in patients with cancer. J Oncol Pract 13:e881-e888, 2017.

16. Lebenthal J, Barile D, Sedhom R: Does use of the POLST form implicate overall care for patients with advanced cancer syndromes? 2017 Palliative and Supportive Care in Oncology Symposium. Abstract 15. Presented October 28, 2017.

17. Mirarchi FL, Yealy DM: Lessons learned from the TRIAD research opportunities to improve patient safety in emergency care near end of life. J Patient Saf. April 4, 2018 (early release online).

18. Clemency B, Cordes CC, Lindstrom HA, et al: Decisions by default: Incomplete and contradictory MOLST in emergency care. J Am Med Dir Assoc 8:35-39, 2017.

19. Mirarchi FL, Doshi AA, Zerkle SW, et al: TRIAD VI: How well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms? J Patient Saf 11:1-8, 2015.

20. Mirarchi FL, Cammarata C, Zerkle SW, et al: TRIAD VII: Do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? J Patient Saf 11:9-17, 2015.

21. Hoffman RM, Mirarchi FL: Empowering patients and agents to help prevent errors with living wills, DNRs, and POLSTs. Pennsylvania Patient Safety Advisory, June 2018. Available at http://patientsafety.pa.gov/ADVISORIES/Pages/201806_DNR.aspx. Accessed August 17, 2018.

22. Graham J: You may have signed a living will, but scary mistakes can happen at the ER. The Washington Post, August 5, 2018. Available at https://elderlawnews.blog/2018/08/14/ you-may-have-signed-a-living-will-but-scary-mistakes-can-happen-at-the-er. Accessed August 17, 2018.

23. Cottingham AH, Beck-Coon K, Bernat JK, et al: Addressing personal barriers to advance care planning: Qualitative investigation of a mindfulness-based intervention for adults with cancer and their family caregivers. Palliat Support Care. June 8, 2018 (early release online).

24. Nugnet S, Golden S, Ganzini L, et al: POLST utilization among veterans with advanced-stage lung cancer. Am J Respir Crit Care Med 197:A4877, 2018.

25. Lammers AJ, Zive DM, Tolle SW, et al: The oncology specialist’s role in POLST form completion. Am J Hosp Palliat Care 35:297-303, 2018.

26. Swetz KM: Are Physician Orders for Life-Sustaining Treatments the answer to the end-of-life care quality conundrums in cancer care? J Oncol Pract 14:7-8, 2018.

27. Moore KA, Rubin EB, Halpern SD: The problems with Physician Orders for Life-Sustaining Treatment. JAMA 315:259-260, 2016.

28. Zive DM, Fromme EK, Schmidt TA, et al: Timing of POLST form completion by cause of death. J Pain Symptom Manage 50:650-658, 2015.

29. Sabatino C: POLST: Avoid the seven deadly sins. Bifocal 39:55-58 2018.

30. Tolle SW, Teno JM: Counting POLST form completion can hinder quality. Health Affairs Blog, July 19, 2018. Available at www.healthaffairs.org/do/10.1377/hblog20180709.244065/full. Accessed August 17, 2018.

31. National POLST Paradigm. Available at http://polst.org. Accessed August 17, 2018.


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