Key Points
Question
For patients with treatment-limiting Physician Orders for Life-Sustaining Treatment (POLST) hospitalized near the end of life, how often is their inpatient care consistent with POLST-ordered limitations?
Findings
In this retrospective cohort study of 1818 decedents with POLSTs who were hospitalized within 6 months of death, rates of intensive care unit (ICU) admission differed significantly by POLST order for medical interventions (31% for those who indicated “comfort measures only,” 46% for those who indicated “limited additional interventions,” and 62% for those who indicated “full treatment”).
Meaning
For patients hospitalized near the end of life, treatment-limiting POLSTs were associated with significantly lower rates of ICU admission compared with full-treatment POLSTs, although many patients with treatment-limiting POLSTs received care that was potentially discordant with their POLST.
Abstract
Importance
Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations.
Objectives
To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life.
Design, Setting, and Participants
Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system.
Exposures
POLST order for medical interventions (“comfort measures only” vs “limited additional interventions” vs “full treatment”), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury.
Main Outcomes and Measures
The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life.
Results
Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]).
Conclusions and Relevance
Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.
This cohort study uses electronic health record (EHR) data to evaluate the association between Physician Orders for Life-Sustaining Treatment (POLST) and intensive care unit (ICU) admission and the incidence of and risk factors for POLST-discordant intensive care among adult patients hospitalized 6 months or less before death.
Introduction
Approximately 20% to 30% of people in the United States are admitted to an intensive care unit (ICU) near the end of life.1,2 However, many patients with chronic illness prioritize symptom relief over life extension,3,4 and ICU admission may be potentially unwanted and inconsistent with their goals. To reduce goal-discordant care, one widely implemented approach to documenting treatment preferences in advance is the Physician Orders for Life-Sustaining Treatment (POLST), a portable medical order with treatment limitations for emergency care.5 Treatment-limiting POLSTs have been associated with less in-hospital death, hospitalization, and unwanted cardiopulmonary resuscitation (CPR) and with a low incidence of intensive care in nursing home residents.6 However, the associations between POLST order for medical interventions and measures of intensive care in other populations are less studied.
This study evaluated the associations between POLST order for medical interventions and ICU admission, as well as the incidence and predictors associated with POLST-discordant intensive care among adults with chronic life-limiting illness hospitalized near the end of life. POLST-discordant care was defined as admission to the ICU when a preexisting POLST form stated that intensive care should be avoided. First, the study examined whether there were differences in intensive care received near the end of life by type of POLST order, hypothesizing that patients with treatment-limiting POLSTs would receive less intensive care. Second, the study examined potential risk factors for POLST-discordant care among patients with treatment-limiting POLSTs.
The study hypothesized that patients with older age, white and non-Hispanic race/ethnicity, higher educational attainment, or who had signed their own POLST would be at lower risk of POLST-discordant care. Additional hypotheses were that patients with more predictable illness trajectories (eg, cancer or dementia) would be less likely to receive POLST-discordant intensive care than patients without these conditions,7,8 whereas patients with less predictable illnesses (eg, traumatic injury) would be more likely to receive POLST-discordant intensive care.9
Methods
Design, Setting, and Participants
The study design and a waiver of informed consent for participants were approved by the University of Washington institutional review board.
We conducted a retrospective cohort study of decedents with preexisting POLSTs who were hospitalized near the end of life at the 2 teaching hospitals of UW Medicine, which include a quaternary-care academic medical center and a regional tertiary care and level I trauma center. These hospitals function as a unified health care system, sharing medical staff, house staff, policies, and an electronic health record (EHR). At both hospitals, the decision to admit a patient to the ICU is made jointly by the referring clinician and the admitting ICU physician. All ICU patients are cared for by intensivists in a closed-ICU model. UW Medicine has a mature palliative care program that includes educational and quality improvement initiatives spanning the outpatient, inpatient, and ICU settings.
Participants included all individuals who died in Washington State between January 1, 2010, and December 31, 2017; had chronic life-limiting illness; were hospitalized in the last 6 months of life at a study hospital; and had completed a POLST before their last inpatient admission. We used Washington State death certificates to identify decedents in the study period and linked death certificates to EHR records using social security numbers. Chronic life-limiting illness was defined by having any of 9 chronic conditions documented by diagnosis code in the EHR within the last 2 years of life: cancers with poor prognosis (primary malignancies with poor prognoses, leukemias, and metastatic disease), chronic lung disease, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic renal failure, severe chronic liver disease, diabetes with end-organ damage, and dementia. These conditions are used by the Dartmouth Atlas to study end-of-life care in the United States and are associated with 90% of deaths among Medicare beneficiaries.10 We excluded patients younger than 18 years at death and those hospitalized for elective surgery.
The POLST
The Washington State POLST program is a mature, widely disseminated intervention endorsed by the National POLST Paradigm since 2005.11,12 The Washington State POLST is scanned as a paper document into the EHR and is recognized as a medical order in all care settings, including hospitals. While it is customary for hospital personnel to replace POLSTs with hospital-specific resuscitation orders on admission, in-hospital treatment is often guided by POLST orders. POLSTs provide guidance and legal protection to health care workers who follow them, but they are not inviolable; patients or their surrogates may void the POLST and request alternative treatment at any time. Although a POLST may be completed for any patient, POLSTs are intended for patients with “serious chronic or acute illness nearing its end stages or likely to progress to a life-threatening state suddenly.”12 All states’ implementation of POLSTs have an order for whether or not to perform CPR in the event of cardiopulmonary arrest and an order for medical interventions for patients who are ill but not in cardiopulmonary arrest.11 In Washington State, the options for medical interventions orders are “full treatment,” “limited additional interventions” (hereafter, limited interventions), or “comfort measures only” (hereafter, comfort only) (eFigure 1 in the Supplement).
For this study, POLST order for medical interventions, signatory, and completion date were manually abstracted from scanned POLST forms. Abstractors were blinded to study outcomes, and the last POLST preceding the patient’s last hospitalization was used for analysis. Because POLSTs are not used to document real-time changes in inpatients’ treatment limitations, we did not analyze POLSTs completed after hospital admission.
Outcomes
All outcomes were measured during the last hospitalization of life and treated as binary variables. Intensive care was defined in 2 ways: (1) admission to the ICU, and (2) receipt of any of 4 prespecified life-sustaining treatments: mechanical ventilation, vasoactive infusions (dobutamine, dopamine, epinephrine, isoproterenol, milrinone, norepinephrine, phenylephrine, or vasopressin), new dialysis or continuous renal replacement therapy, or CPR. These outcomes were electronically abstracted from structured clinical documentation in the EHR. We considered receipt of CPR anywhere in the hospital to be equivalent to ICU admission. Acute care patients boarding in the ICU because of bed capacity were not considered to have been admitted to the ICU.
Intensive Care by POLST Order
Among all patients with POLSTs, we evaluated the association of POLST order for medical interventions with the primary outcome of ICU admission and the secondary outcome of receipt of 1 or more aforementioned life-sustaining treatments.
POLST-Discordant Intensive Care
Among patients with treatment-limiting POLST order for medical interventions, we evaluated risk factors for the outcome of POLST-discordant intensive care. For patients with comfort-only POLSTs, POLST-discordant intensive care was defined as any ICU admission except admissions for symptom management only. For patients with limited-interventions POLSTs, POLST-discordant intensive care was defined as any ICU admission except admissions for symptom management only and admissions solely for delivery of noninvasive ventilation without additional life-sustaining treatments as specified by the Washington State POLST (eFigure 1 in the Supplement). To identify ICU admissions for symptom management only, we manually reviewed clinician documentation of treatment plans for patients in whom a standardized comfort-care order set was initiated within 24 hours of ICU admission.
Covariates
Age, race/ethnicity, educational attainment, and date and location of death were obtained from death certificates. Death certificate race and ethnicity fields are categorical and typically collected from a family member or other informant; this covariate was included because of previously reported differences in end-of-life care by race/ethnicity. Educational attainment was converted from an 8-category variable to approximate years of education. Chronic life-limiting illnesses, including histories of cancers with poor prognosis and dementia, were measured using diagnosis codes documented over decedents’ last 2 years of life.10 For patients with treatment-limiting POLSTs, the reason for hospital admission was determined by manual chart abstraction; we created a binary variable of admission for traumatic injury vs all other admitting diagnoses. Date of POLST completion was manually abstracted from the POLST as the date accompanying the patient or surrogate’s signature; if this date was not completed, we used the earliest written date on the POLST (typically the date of the clinician’s signature). POLSTs without legible dates were assumed to have been signed on the date they were scanned into the EHR. POLST signatory (patient vs surrogate) was manually abstracted from the signer’s printed name or signature; illegible names/signatures were treated as missing data.
Statistical Analyses
To evaluate the association between the primary outcome of ICU admission and POLST order for medical interventions (comfort only, limited interventions, full treatment), we used modified Poisson regression13 without and with adjustment for age at admission, race/ethnicity, years of education, log-transformed days from POLST completion to admission, history of cancer with poor prognosis, history of dementia, and POLST signatory. POLST order was modeled as a nominal exposure, with full treatment as the referent category. Age, years of education, and log-transformed days from POLST completion to admission were modeled continuously. All other exposures were modeled as binary variables. Similar analyses were performed for the secondary outcome of receipt of life-sustaining treatments. We explored associations between POLST order and individual life-sustaining treatments (eg, mechanical ventilation) using the same approach.
To evaluate potential risk factors for POLST-discordant care among patients with treatment-limiting POLSTs, we used modified Poisson regression13 without and with adjustment for age at admission, race/ethnicity, years of education, log-transformed days from POLST completion to admission, history of cancer with poor prognosis, history of dementia, POLST signatory, and admitting diagnosis of traumatic injury. Age, years of education, and log-transformed days from POLST completion to admission were modeled continuously, and all other exposures were modeled as binary variables. We performed separate analyses by POLST order (comfort only vs limited interventions). Additionally, to explore temporal trends in POLST-discordant care, we performed a secondary analysis that included date of death as a continuous variable using a similar approach.
We used modified Poisson regression with robust (sandwich) estimation of variance applied to binary, nonrepeated outcomes13 instead of logistic regression to allow estimation of relative risk when the rare disease assumption is violated. We used robust (sandwich) estimation of variance, since the mean-variance relationship of the Poisson distribution may be inappropriate for our binary outcomes. Multiple imputation with chained equations was used to impute missing data for race/ethnicity, educational attainment, and POLST signatory. We assumed that data were missing at random and modeled missing data using logistic or linear regression depending on the covariate, as conditioned on the remaining exposures and outcome for each model, stratified by POLST order when appropriate. We ran 20 imputations a priori and assessed adequacy of number of imputations using the largest fraction of missing information for each model. Effect estimates were combined using Rubin rules. Parameter estimates were exponentiated to obtain estimates of relative risk.
Estimates of incidence and relative risks refer to the period from study hospitalization to death, assuming intensive care is not received at another hospital after discharge from the study hospital. To address the sensitivity of results to the latter assumption, we performed additional analyses restricted to patients who died during the study hospitalization.
P < .05 (2-sided) was considered statistically significant. Because of the potential for type I error due to multiple comparisons, findings from analyses of secondary end points should be interpreted as exploratory. Analyses were performed using Stata version 16.0 (StataCorp LLC).
Results
Patient Characteristics
Between January 1, 2010, and December 31, 2017, there were 30 803 potentially eligible adult decedents in Washington State with chronic life-limiting illness who received care through UW Medicine, of whom 14 370 were hospitalized in the last 6 months of life at a study hospital. Of these, 1818 (12.7%) had a POLST that preceded the study hospitalization (Figure 1).
Figure 1. Identification of Eligible Decedents for Cohort of Chronically Ill Patients Hospitalized Near the End of Life With Preceding POLST.
POLST indicates Physician Orders for Life-Sustaining Treatment.
aThe Washington State POLST order for limited additional interventions allows for use of medical treatment, intravenous fluids, and cardiac monitoring as indicated; no use of intubation or mechanical ventilation (though less invasive airway support [eg, continuous positive airway pressure or bi-level positive airway pressure ventilation] may be used); and transfer to hospital if indicated but avoidance of intensive care if possible.
Among 1818 decedents with POLSTs hospitalized near the end of life, the mean age was 70.8 (SD, 14.7) years; 752 (41%) were women; and 450 (26%) were nonwhite or Hispanic (Table 1). Most decedents had more than 1 chronic life-limiting illness (median, 3 [interquartile range, 2-4); 39% had cancer, and 26% had dementia. Of 1818 decedents, 656 (36%) had POLST orders for full treatment, 761 (42%) had orders for limited additional interventions, and 401 (22%) had orders for comfort measures only. Missing data were present for race/ethnicity (5%), education (9%), and POLST signatory (14%) (eTable 1 in the Supplement).
Table 1. Baseline Demographics and Medical Characteristics of Patients With POLSTs Hospitalized Near the End of Life.
| Characteristic | No. (%) | |||
|---|---|---|---|---|
| All Decedents (n = 1818) | POLST Order for Medical Interventions | |||
| Comfort Measures Only (n = 401) | Limited Additional Interventions (n = 761) | Full Treatment (n = 656)a | ||
| Patient Characteristics | ||||
| Age at admission, mean (SD), y | 70.8 (14.7) | 72.3 (14.9) | 73.2 (14.3) | 67.0 (14.3) |
| Sex | ||||
| Male | 1066 (59) | 233 (58) | 433 (57) | 400 (61) |
| Female | 752 (41) | 168 (42) | 328 (43) | 256 (39) |
| Race | (n = 1733) | (n = 386) | (n = 725) | (n = 622) |
| White | 1325 (76) | 313 (81) | 565 (78) | 447 (72) |
| Black | 176 (10) | 26 (7) | 59 (8) | 91 (15) |
| Asian | 169 (10) | 37 (10) | 72 (10) | 60 (10) |
| Otherb | 63 (4) | 10 (3) | 29 (4) | 24 (4) |
| Hispanic ethnicity | 43/1733 (2) | 6/386 (2) | 12/725 (2) | 25/622 (4) |
| Educational attainment | (n = 1657) | (n = 365) | (n = 701) | (n = 591) |
| <High school | 224 (14) | 46 (13) | 92 (13) | 86 (15) |
| High school or GED | 553 (33) | 139 (38) | 223 (32) | 191 (32) |
| Some college | 418 (25) | 88 (24) | 164 (23) | 166 (28) |
| Bachelor’s degree or more | 462 (28) | 92 (25) | 222 (32) | 148 (25) |
| No. of chronic life-limiting illness diagnoses | ||||
| 1 | 427 (23) | 118 (29) | 182 (24) | 127 (19) |
| 2 | 470 (26) | 123 (31) | 195 (26) | 152 (23) |
| 3 | 364 (20) | 85 (21) | 149 (20) | 130 (20) |
| ≥4 | 557 (31) | 75 (19) | 235 (31) | 247 (38) |
| Chronic life-limiting illnesses | ||||
| Congestive heart failure | 758 (42) | 124 (31) | 321 (42) | 313 (48) |
| Coronary artery disease | 753 (41) | 130 (32) | 324 (43) | 299 (46) |
| Cancer with poor prognosis | 716 (39) | 181 (45) | 321 (42) | 214 (33) |
| Chronic lung disease | 712 (39) | 134 (33) | 292 (38) | 286 (44) |
| Chronic renal failure | 687 (38) | 118 (29) | 272 (36) | 297 (45) |
| Dementia | 464 (26) | 111 (28) | 213 (28) | 140 (21) |
| Peripheral vascular disease | 432 (24) | 75 (19) | 175 (23) | 182 (28) |
| Diabetes with end-organ damage | 386 (21) | 63 (16) | 151 (20) | 172 (26) |
| Severe chronic liver disease | 233 (13) | 38 (9) | 81 (11) | 114 (17) |
| POLST Characteristics | ||||
| POLST signatoryc | ||||
| Patient | 1096 (60) | 247 (62) | 473 (62) | 376 (57) |
| Patient surrogate | 461 (25) | 106 (26) | 182 (24) | 173 (26) |
| Unclear (illegible signature) | 261 (14) | 48 (12) | 106 (14) | 107 (16) |
| Days from POLST completion to study hospitalization, median (IQR) | 111.5 (28-369) | 102 (25-335) | 100 (28-353) | 126 (31-418) |
| Study Hospitalization Characteristics | ||||
| Admitted for traumatic injury | NAd | 64 (16) | 91 (12) | NAd |
| Died during study hospitalization | 700 (39) | 142 (35) | 281 (37) | 277 (42) |
Abbreviations: GED, General Education Diploma; IQR, interquartile range; NA, not available; POLST, Physician Orders for Life-Sustaining Treatment.
Patients with full-treatment POLSTs were not included in the analysis of risk factors for POLST-discordant care.
Includes Native American, Pacific Islander, and mixed race.
The Washington State POLST specifies that the POLST must always be signed by the patient unless the patient is “decisionally incapacitated,” in which case a legal surrogate may sign the POLST. Illegible signatures were treated as missing data.
Admission diagnoses not abstracted for patients with full-treatment POLSTs.
POLSTs were completed a median of 111.5 (interquartile range, 28-369) days before hospital admission. At least 1096 POLSTs (60%) were signed by the patient, and at least 461 (25%) were signed by surrogates; 261 (14%) had illegible signatures. Thirty-two POLSTs (1.8%) bore no legible signature date, although all preceded the study hospitalization based on the date they were scanned into the EHR. Among patients with treatment-limiting POLST orders, 13% were admitted to the hospital for traumatic injury. Other reasons for hospital admission are summarized in eTable 2 in the Supplement.
Intensive Care by POLST Order
Among decedents with any POLST order for medical interventions, 878 (48%) were admitted to the ICU during the study hospitalization. The incidence of ICU admission by POLST order was 123/401 (31%) for those with comfort-only orders, 349/761 (46%) for those with limited-interventions orders, and 406/656 (62%) for those with full-treatment orders (Table 2).
Table 2. Intensive Care Delivered to Patients With POLSTs Hospitalized Near the End of Life.
| Care Outcome | POLST Order for Medical Interventions, No. (%) [95% CI]a | P Valueb | ||
|---|---|---|---|---|
| Comfort Measures Only (n = 401) | Limited Additional Interventions (n = 761) | Full Treatment (n = 656) | ||
| Admission to ICU | 123 (31) [26-35] | 349 (46) [42-49] | 406 (62) [58-66]c | <.001 |
| For noninvasive ventilation onlyd | 7 (2) [1-4] | 31 (4) [3-6] | 12 (2) [1-3] | .01 |
| For symptom management onlye | 2 (0.5) [0.1-1.8] | 3 (0.4) [0.1-1.1] | 0 (0) [0-0.6] | .24 |
| Comfort care within 24 h of ICU admission | 53 (13) [10-17] | 66 (9) [7-11] | 15 (2) [1-4] | <.001 |
| Delivery of life-sustaining treatmentsf | 55 (14) [11-17] | 149 (20) [17-23] | 279 (43) [39-46] | <.001 |
| Mechanical ventilationg | 38 (9) [7-13] | 94 (12) [10-15] | 237 (36) [32-40] | <.001 |
| Vasoactive infusions | 32 (8) [6-11] | 91 (12) [10-14] | 182 (28) [24-31] | <.001 |
| New dialysis or CRRT | 0 (0) [0-0.9] | 2 (0.3) [0.0-0.9] | 12 (2) [1-3] | <.001 |
| CPR | 4 (1.0) [0.3-2.5] | 12 (2) [1-3] | 37 (6) [4-8] | <.001 |
| POLST-discordant intensive careh | 121 (30) [26-35] | 315 (41) [38-45] | NA | NA |
| Comfort measures only and limited additional interventions combined | 436 (38) [95% CI, 35-40] | |||
Abbreviations: CPR, cardiopulmonary resuscitation; CRRT, continuous renal replacement therapy; ICU, intensive care unit; NA, not applicable; POLST, Physician Orders for Life-Sustaining Treatment.
All reported values were calculated using the denominator of all patients in each POLST order group.
P value for any association between care outcome and POLST order by χ2 test, or by Fisher exact test when numbers are small (ICU admission only for symptom management, new dialysis, or CRRT).
Includes 2 patients with POLST orders for full treatment who received in-hospital CPR outside of the ICU.
Includes patients who were admitted to the ICU and received noninvasive ventilation, but did not receive any mechanical ventilation, vasoactive infusions, new dialysis/CRRT, or CPR.
Includes patients admitted to the ICU solely for frequency of symptom assessment and management, and patients receiving chronic mechanical ventilation admitted for planned discontinuation of mechanical ventilation.
For patients with comfort-only or limited-interventions POLST orders, delivery of these life-sustaining treatments are defined as POLST-discordant treatments.
Includes 9 patients with POLST orders for comfort only and 19 patients with POLST orders for limited interventions, who were intubated by prehospital care providers (ie, emergency medical services). Does not include patients receiving chronic mechanical ventilation.
POLST-discordant intensive care is defined as (1) ICU admission, excluding admissions only for symptom management, for patients with POLST orders for comfort measures only; or (2) ICU admission apart from admissions indicated solely for delivery of noninvasive ventilation without additional life-sustaining treatments and excluding admissions only for symptom management for patients with POLST orders for limited interventions.
Compared with patients with full-treatment POLSTs, patients with comfort-only or limited-interventions POLSTs were significantly less likely to be admitted to the ICU (comfort only: unadjusted risk, 123/401 [31%] vs 406/656 [62%], adjusted relative risk [aRR], 0.53 [95% CI, 0.45-0.62; P < .001]; limited interventions: unadjusted risk, 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87; P < .001]) and were also significantly less likely to receive life-sustaining treatments (comfort only: unadjusted risk, 55/401 [14%] vs 279/656 [43%], aRR, 0.38 [95% CI, 0.29-0.49; P < .001]; limited interventions: unadjusted risk, 149/761 [20%] vs 279/656 [43%], aRR, 0.53 [95% CI, 0.44-0.63; P < .001]) (Figure 2). In secondary analyses examining individual life-sustaining treatments, treatment-limiting POLST orders were significantly associated with lower likelihoods of mechanical ventilation, vasoactive infusions, or CPR (eFigure 2 in the Supplement).
Figure 2. Associations Between POLST Order for Medical Interventions and Intensive Care Near the End of Life.
EHR indicates electronic health record; POLST, Physician Orders for Life-Sustaining Treatment.
aAdjusted for age at admission, race/ethnicity, education, log-transformed days from POLST completion to study admission, history of cancer with poor prognosis, history of dementia, and POLST signatory.
bCompared with patients having full-treatment POLSTs (406/656).
cCompared with patients having full-treatment POLSTs (279/656).
POLST-Discordant Intensive Care
Among decedents with treatment-limiting POLST orders for medical interventions, ICU admission occurred in 123 of 401 (31%) with comfort-only orders and 349 of 761 (46%) with limited-interventions orders (Table 2). Five (1%) of these ICU admissions were for the sole purpose of symptom management. Although the Washington State POLST allows delivery of noninvasive ventilation to patients with POLST order for limited interventions, only 31 of 761 patients (4%) with limited-interventions POLSTs were admitted to the ICU for noninvasive ventilation without receiving other life-sustaining treatments.
The incidence of POLST-discordant intensive care was 30% (95% CI, 26%-35%) in the comfort-only group and 41% (95% CI, 38%-45%) in the limited-interventions group, for a combined incidence of 38% (95% CI, 35%-40%). The incidence of POLST-discordant delivery of life-sustaining treatments was 14% (95% CI, 11%-17%) in the comfort-only group and 20% (95% CI, 17%-23%) in the limited-interventions group, for a combined incidence of 18% (95% CI, 15%-20%). There was no evidence that the incidence of POLST-discordant intensive care decreased significantly over the 8 years of the study (comfort only: aRR, 1.01 per year [95% CI, 0.94-1.09; P = .70]; limited interventions: aRR, 1.00 per year [95% CI, 0.96-1.04; P = .90]) (eFigure 3 in the Supplement).
In evaluating potential risk factors for POLST-discordant intensive care (Figure 3), patients with a history of cancer were significantly less likely to receive POLST-discordant care compared with patients without cancer in both the comfort-only and the limited-interventions groups (comfort only: unadjusted risk, 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85; P = .004]; limited interventions: unadjusted risk, 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78; P < .001]). Additionally, among patients with comfort-only POLSTs, those with dementia were significantly less likely to receive POLST-discordant care compared with patients without dementia (unadjusted risk, 23/111 [21%] vs 98/290 [34%]; aRR, 0.44 [95% CI, 0.29-0.67; P < .001]); this association was not significant in those with limited-interventions POLSTs (unadjusted risk, 99/213 [46%] vs 216/548 [39%]; aRR, 1.02 [95% CI, 0.84-1.25; P = .82]). In both the comfort-only and the limited-interventions groups, patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care compared with patients without traumatic injury (comfort only: unadjusted risk, 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14; P = .02]; limited interventions: unadjusted risk, 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68; P = .005]). Among patients with limited-interventions POLSTs, older age was also associated with significantly less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00; P = .04]); this association was not observed in patients with comfort-only POLSTs (aRR, 1.01 per 10 years [95% CI, 0.91-1.13; P = .81]). There were no significant associations between POLST-discordant care and non-white race or Hispanic ethnicity, POLST signatory, or days from POLST completion to admission (Figure 3).
Figure 3. Associations Between Patient Characteristics and POLST-Discordant Intensive Care.
POLST indicates Physician Orders for Life-Sustaining Treatment.
aComplete cases only. Omitted for continuous exposures.
bUnadjusted relative risk with multiple imputation of missing data.
cAdjusted for all exposures presented in the figure, separated by POLST order for medical interventions.
dRelative risk per year of formal education.
eThe Washington State POLST specifies that the POLST should always be signed by the patient unless the patient is “decisionally incapacitated,” in which case a legal surrogate may sign the POLST.
fRelative risk per doubling of days from POLST signature to date of admission (ie, log base 2).
Sensitivity analyses restricted to patients who died during the study hospitalization yielded similar associations with expected changes in precision (eFigures 4 and 5 in the Supplement).
Discussion
In this study of patients with POLSTs hospitalized near the end of life, rates of ICU admission and life-sustaining treatments differed significantly by POLST order for medical interventions. Those with full-treatment orders were significantly more likely to receive ICU admission and life-sustaining treatments than those with comfort-only or limited-interventions orders. However, among those with treatment-limiting POLST order for medical interventions, 38% were admitted to the ICU and 18% received mechanical ventilation, vasoactive infusions, dialysis, or CPR.
While several previous studies of patients with POLSTs in nursing homes have reported a much lower incidence of POLST-discordant medical treatments,5,14,15 these studies did not specifically examine care received near the end of life. Studies that specifically examine end-of-life care have had mixed findings. The findings of this study are consistent with those from a prior study of 58 decedents with POLSTs in a comprehensive elder care program, which reported a similar incidence of POLST-discordant care.16 In contrast, 2 prior decedent studies in which POLSTs had been implemented as part of community-wide advance care planning initiatives reported a very low occurrence of POLST-discordant care near the end of life.17,18 These differences are likely explained by differences in sample populations, approaches to POLST completion, and periods for assessing discordant care. In contrast to the structured implementation of POLSTs within interdisciplinary community-wide advance care planning initiatives represented in these prior studies, this study enrolled a diverse group of patients at a large referral health system, where most POLSTs are completed in the course of usual care by clinicians from both UW Medicine and the surrounding community.
Although treatment-limiting POLST orders were significantly associated with lower intensity of care compared with full-treatment POLST orders, 38% of patients with treatment-limiting POLSTs received potentially unwanted intensive care near the end of life. The experiences of ICU patients and survivors suggest that patients receiving aggressive life-sustaining treatments experience a high burden of unrelieved physical symptoms and emotional distress,19,20 a finding echoed in the perspectives of family members of patients who die in the ICU.21,22 Although studies of ICU survivors report that most patients would elect to receive intensive care again, these studies have not examined patients with treatment-limiting POLST forms.23,24 Additionally, intensive care and mechanical ventilation account for a disproportionate amount of health care expenditures within the last years of life.1,25 For patients who do not want aggressive treatments near the end of life, unwanted intensive care may incur physical, emotional, and financial costs while providing little value. Reducing unwanted intensive care near the end of life represents an opportunity to simultaneously improve patient-centered care and reduce costs.26
In evaluating the study outcome, it is important to highlight that differences between POLST-discordant care and goal-discordant or inappropriate care may exist for several reasons. In the setting of acute illness, patients, surrogates, and clinicians may encounter circumstances that ethically compel a different treatment course than that outlined by a previously completed POLST; accordingly, many patients with treatment limitations are willing to grant leeway to future decision-makers.27 Nevertheless, it is possible that many cases of POLST-discordant care represent potentially inappropriate care near the end of life, and further study is needed to understand why this happens.
Four factors were identified as independently associated with POLST-discordant intensive care. First, dementia was associated with significantly lower risk of POLST-discordant care in patients with comfort-only POLSTs. This finding is consistent with prior studies showing increased effectiveness of advance directives in reducing intensity of end-of-life care among patients with cognitive impairments.28
Second, cancer was associated with significantly lower risk of POLST-discordant intensive care. This is also consistent with prior studies.29 Although patients with cancer complete POLST forms later in their disease course than those with organ failure or dementia,30 the association observed was independent of POLST timing.
Third, patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care. This finding complements a prior study that found no difference in trauma-related ICU admission rates between patients with and without treatment-limiting POLSTs.31 These findings may be related to the time pressure of trauma care; additionally, traumatic injury may be an uncommon scenario considered in the shared decision-making that informs a patient’s POLST order.32 Although POLSTs are designed to apply to all clinical circumstances, divergence of actual acute illness (eg, hip fracture) from the anticipated clinical scenarios that inform POLST order (eg, exacerbation of chronic disease) may lead patients, surrogates, or clinicians to choose more aggressive care than that designated by POLST order.33,34
Fourth, in adjusted analyses, older age was independently associated with a significant decrease in POLST-discordant care among those with limited-interventions POLSTs but not among those with comfort-only POLSTs. This finding is consistent with prior studies that have found older age to be associated with decreased intensity of care.35,36
The results of this study support the overall hypothesis that patients with less predictable prognostic trajectories7,8 may receive more intense and more POLST-discordant care near the end of life. This may be because of prognostic uncertainty biasing clinicians and decision-makers toward more aggressive care, unanticipated clinical developments that bring the applicability of POLST orders into question, prevailing care processes for specific illnesses that favor aggressive care, or differences in care that facilitate or impede the communication and interpretation of patients’ values, goals, and treatment preferences.33,34,37
There were no significant associations between POLST-discordant care and race/ethnicity, educational attainment, or decision-making capacity at the time of POLST completion (assessed by whether the patient was able to sign his or her own POLST). Minority race and ethnicity have been associated with less advance directive completion and greater intensity of end-of-life care,38 although there is emerging evidence that these differences may be explained by differences in care delivery.39 The racial and ethnic composition of this study sample limits the ability to draw conclusions that generalize to other settings. There was also no significant association between POLST-discordant intensive care and date of death over the 8-year study period, suggesting that increasing experience with POLST forms is not reducing POLST-discordant intensive care.
Limitations
This study has several limitations. First, by enrolling patients with POLSTs hospitalized near the end of life and measuring POLST-discordant care in the hospital, these findings do not apply to patients with POLSTs who are not hospitalized near the end of life (as may be the case when care is aligned with a comfort-only POLST). Therefore, the results of this study may overestimate the incidence of POLST-discordant care among all patients with POLSTs.
Second, the study only included POLST-discordant care that occurred at the study hospitals and may misclassify patients who received POLST-discordant care at another hospital or from emergency medical services without subsequent transfer to a study hospital. Such misclassification would result in underestimation of the incidence of POLST-discordant care from the time of study hospitalization to death.
Third, by enrolling decedents, the study is unable to evaluate POLST-discordant care delivered to individuals who go on to survive their critical illness. This concern is tempered by the high mortality of critical illness among individuals with chronic life-limiting illness; additionally, examining decedents allowed the study to specifically evaluate care received near the end of life—a critical period for the intended function of the POLST.5
Fourth, the study only included POLSTs on file at the study hospitals. However, the observed uptake of POLSTs in this study (12.7%) is similar to statewide estimates of POLST uptake (13%) (Jessica Martinson, MS, Washington State Medical Association, email communication, January 2019).
Fifth, data from death certificates, claims data, and the EHR are susceptible to misclassification.40,41 To mitigate this, all outcome data were corroborated using multiple sources (eg, by linking claims and clinical data or by corroborating with manual abstraction).
Sixth, analyses did not account for differences in care between the 2 hospitals within UW Medicine. Because each study hospital houses unique subspecialty centers (eg, cancer center, trauma center), hospital site is in the causal pathway for several exposures of interest. Because both hospitals share a common medical staff, policies, management, and culture, the observed differences in care are more likely to be due to patient differences.
Conclusions
Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was discordant with their POLST.
eFigure 1. Washington State POLST Form (February 2011 Revision)
eFigure 2. Associations Between POLST Order for Medical Interventions and Individual Life-Sustaining Treatments Near the End of Life
eFigure 3. Incidence of POLST-Discordant Intensive Care by Year of Death
eFigure 4. Associations Between POLST Order for Medical Interventions and Intensive Care Near the End of Life Among Patients who Died During the Study Hospitalization
eFigure 5. Associations Between Patient Characteristics and POLST-Discordant Intensive Care Among Patients who Died During the Study Hospitalization
eTable 1. Summary of Missing Covariates by POLST Order for Medical Interventions
eTable 2. Hospital Admissions Among POLST Users Near the End of Life
Section Editor: Derek C. Angus, MD, MPH, Associate Editor, JAMA (angusdc@upmc.edu).
References
- 1.Angus DC, Barnato AE, Linde-Zwirble WT, et al. ; Robert Wood Johnson Foundation ICU End-of-Life Peer Group . Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. doi: 10.1097/01.CCM.0000114816.62331.08 [DOI] [PubMed] [Google Scholar]
- 2.Teno JM, Gazolo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470-477. doi: 10.1001/jama.2012.207624 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Teno JM, Fisher ES, Hamel MB, Coppola K, Dawson NV. Medical care inconsistent with patients’ treatment goals: association with 1-year Medicare resource use and survival. J Am Geriatr Soc. 2002;50(3):496-500. doi: 10.1046/j.1532-5415.2002.50116.x [DOI] [PubMed] [Google Scholar]
- 4.Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol. 2010;28(7):1203-1208. doi: 10.1200/JCO.2009.25.4672 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc. 1998;46(9):1097-1102. doi: 10.1111/j.1532-5415.1998.tb06647.x [DOI] [PubMed] [Google Scholar]
- 6.Hickman SE, Keevern E, Hammes BJ. Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature. J Am Geriatr Soc. 2015;63(2):341-350. doi: 10.1111/jgs.13248 [DOI] [PubMed] [Google Scholar]
- 7.Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387-2392. doi: 10.1001/jama.289.18.2387 [DOI] [PubMed] [Google Scholar]
- 8.Lunney JR, Albert SM, Boudreau R, et al. ; Health Aging and Body Composition Study . Mobility trajectories at the end of life: comparing clinical condition and latent class approaches. J Am Geriatr Soc. 2018;66(3):503-508. doi: 10.1111/jgs.15224 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Scarlet S. Caring for the wounded: the ethics of trauma surgery. AMA J Ethics. 2018;20(5):421-424. [Google Scholar]
- 10.Dartmouth Institute for Health Policy and Clinical Practice End-of-life care. Dartmouth Atlas Project website. https://www.dartmouthatlas.org/keyissues/issue.aspx?con=2944. Accessed June 29, 2017.
- 11.POLST programs in your state. National POLST website. https://www.polst.org/programs-in-your-state/. Accessed September 4, 2018.
- 12.Washington State Medical Association (WSMA) Physician Orders for Life-Sustaining Treatment (POLST). WSMA website. https://wsma.org/POLST. Accessed September 19, 2019.
- 13.Zou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702-706. doi: 10.1093/aje/kwh090 [DOI] [PubMed] [Google Scholar]
- 14.Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the Physician Orders for Life-Sustaining Treatment form. J Am Geriatr Soc. 2011;59(11):2091-2099. doi: 10.1111/j.1532-5415.2011.03656.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the Physician Orders for Life-Sustaining Treatment program. J Am Geriatr Soc. 2010;58(7):1241-1248. doi: 10.1111/j.1532-5415.2010.02955.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Lee MA, Brummel-Smith K, Meyer J, Drew N, London MR. Physician Orders for Life-Sustaining Treatment (POLST): outcomes in a PACE program. J Am Geriatr Soc. 2000;48(10):1219-1225. doi: 10.1111/j.1532-5415.2000.tb02594.x [DOI] [PubMed] [Google Scholar]
- 17.Hammes BJ, Rooney BL, Gundrum JD, Hickman SE, Hager N. The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliat Med. 2012;15(1):77-85. doi: 10.1089/jpm.2011.0178 [DOI] [PubMed] [Google Scholar]
- 18.Hopping-Winn J, Mullin J, March L, Caughey M, Stern M, Jarvie J. The progression of end-of-life wishes and concordance with end-of-life care. J Palliat Med. 2018;21(4):541-545. doi: 10.1089/jpm.2017.0317 [DOI] [PubMed] [Google Scholar]
- 19.Puntillo KA, Arai S, Cohen NH, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38(11):2155-2160. doi: 10.1097/CCM.0b013e3181f267ee [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu OJ. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry. 2008;30(5):421-434. doi: 10.1016/j.genhosppsych.2008.05.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292. doi: 10.1001/jama.2015.18604 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Teno JM, Mor V, Ward N, et al. Bereaved family member perceptions of quality of end-of-life care in U.S. regions with high and low usage of intensive care unit care. J Am Geriatr Soc. 2005;53(11):1905-1911. doi: 10.1111/j.1532-5415.2005.53563.x [DOI] [PubMed] [Google Scholar]
- 23.Chelluri L, Pinsky MR, Donahoe MP, Grenvik A. Long-term outcome of critically ill elderly patients requiring intensive care. JAMA. 1993;269(24):3119-3123. doi: 10.1001/jama.1993.03500240063027 [DOI] [PubMed] [Google Scholar]
- 24.Mendelsohn AB, Chelluri L. Interviews with intensive care unit survivors: assessing post-intensive care quality of life and patients’ preferences regarding intensive care and mechanical ventilation. Crit Care Med. 2003;31(5)(suppl):S400-S406. doi: 10.1097/01.CCM.0000065278.90460.F0 [DOI] [PubMed] [Google Scholar]
- 25.Wunsch H, Linde-Zwirble WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010;38(10):1947-1953. doi: 10.1097/CCM.0b013e3181ef4460 [DOI] [PubMed] [Google Scholar]
- 26.Curtis JR, Engelberg RA, Bensink ME, Ramsey SD. End-of-life care in the intensive care unit: can we simultaneously increase quality and reduce costs? Am J Respir Crit Care Med. 2012;186(7):587-592. doi: 10.1164/rccm.201206-1020CP [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Puchalski CM, Zhong Z, Jacobs MM, et al. Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. J Am Geriatr Soc. 2000;48(S1):S84-S90. doi: 10.1111/j.1532-5415.2000.tb03146.x [DOI] [PubMed] [Google Scholar]
- 28.Nicholas LH, Bynum JP, Iwashyna TJ, Weir DR, Langa KM. Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia. Health Aff (Millwood). 2014;33(4):667-674. doi: 10.1377/hlthaff.2013.1258 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Tschirhart EC, Du Q, Kelley AS. Factors influencing the use of intensive procedures at the end of life. J Am Geriatr Soc. 2014;62(11):2088-2094. doi: 10.1111/jgs.13104 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Zive DM, Fromme EK, Schmidt TA, Cook JN, Tolle SW. Timing of POLST form completion by cause of death. J Pain Symptom Manage. 2015;50(5):650-658. doi: 10.1016/j.jpainsymman.2015.06.004 [DOI] [PubMed] [Google Scholar]
- 31.Ballou JH, Dewey EN, Zonies DH. Elderly patients presenting to a level I trauma center with Physician Orders for a Life-Sustaining Treatment form: a propensity-matched analysis. J Trauma Acute Care Surg. 2019;87(1):153-160. doi: 10.1097/TA.0000000000002321 [DOI] [PubMed] [Google Scholar]
- 32.Kim J, Engelberg RA, Downey L, et al. Predictors of advance care planning documentation in patients with underlying chronic illness who died of traumatic injury. J Pain Symptom Manage. 2019;58(5):857-863. doi: 10.1016/j.jpainsymman.2019.07.015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153(4):256-261. doi: 10.7326/0003-4819-153-4-201008170-00008 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Perkins HS. Controlling death: the false promise of advance directives. Ann Intern Med. 2007;147(1):51-57. doi: 10.7326/0003-4819-147-1-200707030-00008 [DOI] [PubMed] [Google Scholar]
- 35.Parr JD, Zhang B, Nilsson ME, et al. The influence of age on the likelihood of receiving end-of-life care consistent with patient treatment preferences. J Palliat Med. 2010;13(6):719-726. doi: 10.1089/jpm.2009.0337 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Turnbull AE, Lau BM, Ruhl AP, Mendez-Tellez PA, Shanholtz CB, Needham DM. Age and decisions to limit life support for patients with acute lung injury: a prospective cohort study. Crit Care. 2014;18(3):R107. doi: 10.1186/cc13890 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Visser M, Deliens L, Houttekier D. Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review. Crit Care. 2014;18(6):604. doi: 10.1186/s13054-014-0604-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Byhoff E, Harris JA, Langa KM, Iwashyna TJ. Racial and ethnic differences in end-of-life medicare expenditures. J Am Geriatr Soc. 2016;64(9):1789-1797. doi: 10.1111/jgs.14263 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Hart JL, Gabler NB, Cooney E, et al. Are demographic characteristics associated with advance directive completion? a secondary analysis of two randomized trials. J Gen Intern Med. 2018;33(2):145-147. doi: 10.1007/s11606-017-4223-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Feder SL. Data quality in electronic health records research: quality domains and assessment methods. West J Nurs Res. 2018;40(5):753-766. doi: 10.1177/0193945916689084 [DOI] [PubMed] [Google Scholar]
- 41.Glasser JH. The quality and utility of death certificate data. Am J Public Health. 1981;71(3):231-233. doi: 10.2105/AJPH.71.3.231 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure 1. Washington State POLST Form (February 2011 Revision)
eFigure 2. Associations Between POLST Order for Medical Interventions and Individual Life-Sustaining Treatments Near the End of Life
eFigure 3. Incidence of POLST-Discordant Intensive Care by Year of Death
eFigure 4. Associations Between POLST Order for Medical Interventions and Intensive Care Near the End of Life Among Patients who Died During the Study Hospitalization
eFigure 5. Associations Between Patient Characteristics and POLST-Discordant Intensive Care Among Patients who Died During the Study Hospitalization
eTable 1. Summary of Missing Covariates by POLST Order for Medical Interventions
eTable 2. Hospital Admissions Among POLST Users Near the End of Life