Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Health Services Research and Development, VA Portland Health Care System, Portland, OR; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.
Ann Emerg Med. 2020 Feb;75(2):171-180. doi: 10.1016/j.annemergmed.2019.05.008. Epub 2019 Jun 24.
Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED).
This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment.
A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61).
Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.
医师签署的维持生命治疗医嘱（POLST）旨在帮助防止在接近生命终点的晚期疾病或虚弱患者中提供不必要的医疗干预。我们试图评估 POLST 表格的完成情况、治疗限制或两者对急诊部门（ED）就诊患者的治疗强度的影响。
这是一项回顾性队列研究，纳入了 2015 年 4 月至 2016 年 10 月期间在俄勒冈州一所学术医疗中心就诊的成年人。POLST 表格的完成情况和治疗限制是主要暴露因素。主要结局是住院；次要结局包括 ICU 入院和强化治疗的综合指标。
共纳入 26128 名患者；其中 1769 名（6.8%）完成了 POLST 表格。在有 POLST 的患者中，52.1%有完整的治疗医嘱，6.4%在入院前其表格被查阅过。POLST 表格的完成情况与住院（调整后的优势比[aOR]=0.97；95%置信区间[CI]0.84 至 1.12）、ICU 入院（aOR=0.82；95%CI0.55 至 1.22）或强化治疗（aOR=1.06；95%CI0.75 至 1.51）无关。与有完整治疗医嘱的 POLST 表格相比，有治疗限制的 POLST 表格与住院（aOR=1.12；95%CI0.92 至 1.37）或强化治疗（aOR=0.87；95%CI0.5 至 1.52）无关，但与 ICU 入院的几率较低相关（aOR=0.31；95%CI0.16 至 0.61）。
在 ED 就诊的患者中，大多数 POLST 表格都有完整治疗的医嘱，并且没有被急诊医生查阅过。这些发现可能部分解释了为什么我们发现 POLST 与治疗强度无关。然而，POLST 表格上的治疗限制与 ICU 入院几率的降低有关。在考虑 POLST 对提供符合患者意愿的治疗的影响时，POLST 表格的实施和可及性至关重要。
