Underutilization of Portable Orders for Life-Sustaining Treatment at Discharge from Hospital: Observational Study at US Academic Trauma Center.

BACKGROUND

Decisions to limit use of life-sustaining treatment occur frequently during hospitalizations, and portable medical orders (also known as Portable Orders for Life-Sustaining Treatment (POLST)) can ensure that patient preferences regarding resuscitation are followed after discharge.

OBJECTIVE

To determine the frequency and predictors of completion of POLST orders for adults with change during hospitalization in resuscitation status to Do Not Resuscitate.

DESIGN

Retrospective observational study at level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All adults (18 years or older) hospitalized between June 2017 and June 2018, inclusive, with code status changed from Full Code to DNR. For patients with more than one hospitalization during this study interval, only the first hospitalization when DNR was ordered was included in this analysis.

MAIN MEASURES

Completion of POLST orders by time of discharge.

KEY RESULTS

From 2017 to 2018, 160 adults had a change from Full Code to DNR status during index hospitalization and survived to discharge, most (156 patients) to a nursing care facility. Of these, only 50 (31.2%) had POLST orders provided at discharge. Documentation of informed refusal of intubation in addition to DNR status was a significant predictor (OR 4.1, 99% CI 1.5-11.0) of POLST orders on discharge, as was admission to a medical service compared with non-medical service (OR 3.2, 99% CI 1.1-12.2). Palliative care consultants, rather than primary providers on the hospital services, completed most POLST orders.

CONCLUSIONS

Despite primary hospital providers engaging in conversations regarding resuscitation and entering DNR orders during hospitalization, the majority of patients in our study discharged to other care facilities without POLST orders. POLST orders are a simple palliative care tool available to primary hospital providers to help ensure continuity of plan of care at discharge for patients who wish to avoid invasive life-sustaining treatments and/or cardiopulmonary resuscitation.