Many patients with a do not resuscitate (DNR) order at the time of hospitalization assume that future healthcare providers will automatically know about their chosen code status. This is not necessarily the case.
“Seriously ill patients often return or readmit to the ED [emergency department] or hospital, and prior code status elections do not carry forward. This can lead to patients receiving care outside of their wishes — and notable distress for them and their families,” says Kathleen Drago, MD, FACP, an associate professor of medicine at Oregon Health & Science University Hospital’s Division of General Internal Medicine & Geriatrics.
Having a DNR Portable Orders for Life-Sustaining Treatment (POLST) form in place ensures that patients’ stated wishes are followed at future visits. Lack of a DNR POLST causes some patients to receive unwanted care when they return to the ED or hospital. “POLST — and similar, yet differently named forms — plays an important role in ensuring patients receive only the care that they want, no more and no less,” says Drago.
The POLST form is durable, meaning it travels with the patient through all settings of care. Providers in all settings are trained to look for, ask about, and access existing POLST forms. In contrast, simple code status orders are limited to the time the patient is actively hospitalized and do not travel with the patient between settings of care. “Additionally, POLST carries the weight of a provider order, where advance directives and living wills do not,” notes Drago.
People who want to avoid resuscitation are at great risk of receiving unwanted invasive care outside of the hospital or in a subsequent ED visit without a durable way to communicate DNR wishes. “This is where a POLST form can fill a dangerous gap,” says Drago.
The POLST form documents DNR wishes and provides actionable medical orders, protecting against unwanted resuscitation and invasive care. Ideally, patients desiring DNR status in the hospital complete a POLST with their providers before leaving the hospital.
Drago and colleagues wanted to know how many hospitalized internal medicine patients were DNR status and did not already have a DNR POLST on file at admission. “Our goal was to understand how many missed opportunities there were,” says Drago. The researchers conducted a preliminary retrospective review of one year’s worth of internal medicine admissions who had been discharged from the hospital and determined that only 29.5% of the patients who were admitted with a DNR order in place also had a DNR POLST on file at the time of admission.
Barriers to POLST completion are well-established.1,2 Providers may lack time for complex discussions, and many are not knowledgeable about POLST forms. Some believe that POLST forms should be completed only by primary care physicians or long-term specialty care providers. “We struggle with the same barriers that many other health systems struggle with, that have been well-documented in the medical literature,” reports Drago.
To improve POLST completion rates for patients being discharged who already had a DNR code status, Drago and colleagues initiated a quality improvement project.3 Over a 34-month time frame, Plan-Do-Study-Act (PDSA) cycles (a change management tool to analyze results of system changes in real time) were conducted. These changes were made:
• A hospitalist provided training on electronic POLSTs to internal medicine residents who provide clinical care to admitted patients.
The training focused on how to complete an electronic POLST and on strategies for having the conversation. Providers do not need to start from scratch when having this discussion, since they can build on the initial code status discussion that happened earlier in the admission. “As providers are fond of saying, advance care planning is a journey, not an end point,” says Drago.
• A discharge navigator notification was embedded into the discharge order process.
Providers were reminded that anyone choosing DNR code status should leave with a completed POLST form. This notification already existed for patients being discharged to another facility. “We adapted it for the discharge-to-home process, which is a different workstream in our EHR [electronic health record],” explains Drago. The reminder was embedded at a certain point in the discharge order process, where it would not significantly disrupt workflow.
The researchers analyzed charts of 387 patients who had been admitted with a DNR order and discharged and found that 36% were discharged with a DNR POLST form. After three PDSA cycles, 60% of eligible patients were leaving with a new POLST form. “This successful leveraging of POLST upstream in patient care likely reduced unwanted care and prevented conflicts that would have prompted palliative care or ethics involvement,” says Drago.
- An HJ, Jeon HJ, Chun SH, et al. Feasibility study of physician orders for life-sustaining treatment for patients with terminal cancer. Cancer Res Treat 2019;51:1632-1638.
- Mack DS, Dosa D. Improving advanced care planning through physician orders for life-sustaining treatment (POLST) expansion across the United States: Lessons learned from state-based developments. Am J Hosp Palliat Care 2020;37:19-26.
- Harmon D, De Lima B, Littlefield K, et al. A quality improvement initiative to increase documentation of preferences for life-sustaining treatment in hospitalized adults. Jt Comm J Qual Patient Saf 2023;Sept 28:S1553-7250(23)00229-5. [Online ahead of print].
