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Confusion on End-of-Life Forms Can Cause Elder Patients to Receive More Emergency Care Than Desired
In recent years, Physicians' Orders for Life Sustaining Treatments (POLST) forms have been seen as an important way to honor the end-of-life wishes of frail elder or terminally ill patients who cannot speak for themselves.

But while the goal of filling out POLST forms is to let providers know patients' preferences regarding life-sustaining treatments, the information they contain is often ambiguous, a new University at Buffalo study has found.

Published online recently in the Journal of the American Medical Directors Association, the study is called "Decisions by Default: Incomplete and Contradictory POLST in Emergency Care."

"We called it 'Decisions by Default' to make patients aware that if they don't make a decision about a specific life-sustaining treatment, then in an emergency, they will most likely get the most aggressive treatment available," says Brian Clemency, DO, an associate professor in the Department of Emergency Medicine in the Jacobs School of Medicine and Biomedical Sciences at UB and first author on the paper. He also is a physician with UBMD Emergency Medicine. Deborah P. Waldrop, PhD, professor in the UB School of Social Work and a nationally- recognized expert on palliative care, is senior author. The study was conducted in the emergency department of Erie County Medical Center (ECMC), a partner hospital of the Jacobs School of Medicine and Biomedical Sciences, where Clemency is an emergency medicine attending physician.

"In emergency medicine, we are trained to do everything we can to prolong life," Clemency says. "The goal of this paper is to help us as emergency medicine physicians honor our patients' wishes as much as possible."

Strictly speaking, the study's focus was not on the patients themselves but on the forms that had been completed before their emergency. In New York State, the forms are called Medical Orders for Life Sustaining Treatment, or MOLST, forms.

One hundred MOLST forms were collected from patients arriving at the emergency department. Items included on the form cover whether or not patients requested CPR, do not resuscitate (DNR) orders, intubation, hospitalization, intravenous fluids, feeding tubes and antibiotics.

Incomplete forms

Of the 100 forms collected, 69% were incomplete with at least one section left blank. That may compel emergency medicine providers to perform interventions the patient would not have wanted.

"We want to do what the patient wants," explains Clemency, "but if you don't tell us what you want, we're forced to assume you want 'everything' done."

Waldrop, who has spent her career working to provide families dealing with end-of-life issues with better options, says that the research demonstrates a need for greater training among primary care providers.

"Primary care providers are having these difficult conversations with their patients," says Waldrop. "More education and training are needed to help them be comfortable guiding people with serious illnesses to effectively communicate their wishes about life-sustaining treatment."

That means going over any inconsistencies in the patients' responses, Clemency says. For example, if a patient says they don't want any life-saving interventions but they do want a breathing tube inserted, Clemency said that that discrepancy may reflect a lack of understanding on the part of the patient and should be questioned by the physician.

"I think the doctor's job is to guide the patient through it and ask them about the implications of their decisions," says Clemency.

Waldrop noted that the forms about life-sustaining treatment and the conversations about them are a major step toward improving end-of-life care for patients, but there is room for improvement.

"This research shows that to be effective in reflecting patients' wishes, these forms need to be filled out completely and without contradictory orders after an informed conversation between a primary care provider and the patient," she says.

Improving communication

"Our hope is that this paper will improve communication between patients and providers, better informing the end-users, the emergency medicine doctors who typically meet these patients when they arrive at the emergency department at 3 AM," Clemency adds.

And it isn't only the emergency physicians who need more clarity, he notes. Families need it too.

"You already have many stressors when an elder parent is ill," Clemency says, "but if the parents' wishes aren't clearly articulated, you might have multiple children, all of whom have the best of intentions, each of whom has a different understanding of what that parent wanted.

"Patients and their families can only benefit when the patients' wishes are clearly articulated."