Abstract
Objective
To assess whether medical orders within Physician Orders for Life-Sustaining Treatment
(POLST) forms reflect patients' preferences for care at the end of life.
Design
This cross-sectional study assessed the agreement between medical orders in POLST
forms and the free-form text documentation of an advance care planning conversation
performed by an independent researcher during a single episode of hospitalization.
Setting and Participants
Inpatients at a single public university hospital, aged 21 years or older, and for
whom one of their attending physicians provided a negative answer to the following
question: “Would I be surprised if this patient died in the next year?” Data collection
occurred between October 2016 and September 2017.
Measures
Agreement between medical orders in POLST forms and the free-form text documentation
of an advance care planning conversation was measured by kappa statistics.
Results
Sixty-two patients were interviewed. Patients' median (interquartile range) age was
62 (56-70) years, and 21 patients (34%) were women. Overall, in 7 (11%) cases, disagreement
in at least 1 medical order for life-sustaining treatment was found between POLST
forms and the content of the independent advance care planning conversation. The kappa
statistic for cardiopulmonary resuscitation was 0.92 [95% confidence interval (CI):
0.82-1.00]; for level of medical intervention, 0.90 (95% CI: 0.81-0.99); and for artificially
administered nutrition, 0.87 (95% CI: 0.75-0.98).
Conclusions and Implications
The high level of agreement between medical orders in POLST forms and the documentation
in an independent advance care planning conversation offers further support for the
POLST paradigm. In addition, the finding that the agreement was not 100% underscores
the need to confirm frequently that POLST medical orders accurately reflect patients'
current values and preferences of care.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The evolution of health care advance planning law and policy.Milbank Q. 2010; 88: 211-239
- POLST: An improvement over traditional advance directives.Cleve Clin J Med. 2012; 79: 457-464
- Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life.The National Academies Press, Washington, DC2015
- Lessons from Oregon in embracing complexity in end-of-life care.N Engl J Med. 2017; 376: 1078-1082
- Programs in your state.(Available at:)http://polst.org/programs-in-your-state/Date accessed: June 12, 2018
- Cross-cultural adaptation of the Physician Orders for Life-Sustaining Treatment form to Brazil.J Palliat Med. 2018; 21: 815-819
- Ethical challenges in advance care planning during the COVID-19 pandemic.Am J Bioethics. 2020; 20: 202-204
- COVID-19: Proactive Care Planning and Respecting the Patient and Family Choice.(Available at:)https://www.aha.org/system/files/media/file/2020/05/COVID-19-Proactive-Care-Planning.pdfDate accessed: September 3, 2020
- 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: 341-350
- Evaluation of the interrater reliability of end-of-life medical orders in the physician orders for life-sustaining treatment form.JAMA Netw Open. 2019; 2: e192036
- Prognostic significance of the “surprise” question in cancer patients.J Palliat Med. 2010; 13: 837-840
- Assessment of patients’ competence to consent to treatment.N Engl J Med. 2007; 357: 1834-1840
- A reliability and validity study of the Palliative Performance Scale.BMC Palliat Care. 2008; 7: 10
- A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.J Chronic Dis. 1987; 40: 373-383
- Redefining the “planning” in advance care planning: Preparing for end-of-life decision making.Ann Intern Med. 2010; 153: 256-261
- California POLST Education Program, Coaliation for Compassionate Care of California: California.2012
- Oregon 2019 POLST form. POLST Oregon.(Available at:)
- California 2016 POLST form. POLST in 2016.(2014. Available at:)https://capolst.org/wp-content/uploads/2015/12/2016_CA_POLST_English.pdfDate accessed: June 25, 2018
- The measurement of interrater agreement.in: Statistical Methods for Rates and Proportions. John Wiley, New York2003: 598-626
- The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: A clarification of its content.BMC Med Res Methodol. 2010; 10: 22
- COSMIN checklist manual.(2012. Available at:)http://www.cosmin.nl/images/upload/files/COSMIN%20checklist%20manual%20v9.pdfDate accessed: September 1, 2014
- The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An international Delphi study.Qual Life Res. 2010; 19: 539-549
- The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes.J Clin Epidemiol. 2010; 63: 737-745
- Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies.BMJ. 2007; 335: 806-808
- Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed.J Clin Epidemiol. 2011; 64: 96-106
- Altman D. Machin D. Bryant T. Gardner M. Statistics with Confidence: Confidence Intervals and Statistical Guidelines. 2nd ed. BMJ Books, Hoboken, NJ2000
- Biostatistics: The Bare Essentials.4th ed. People's Medical Publishing House, Beijing2014
- Weighted kappa: Nominal scale agreement provision for scaled disagreement or partial credit.Psychol Bull. 1968; 70: 213-220
- A goodness-of-fit approach to inference procedures for the kappa statistic: Confidence interval construction, significance-testing and sample size estimation.Stat Med. 1992; 11: 1511-1519
- Comparison of classification accuracy using Cohen's weighted kappa.Expert Syst Appl. 2008; 34: 825-832
- A confidence interval approach to sample size estimation for interobserver agreement studies with multiple raters and outcomes.J Clin Epidemiol. 2012; 65: 778-784
- Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: Beyond resuscitation status.J Am Geriatr Soc. 2004; 52: 1424-1429
- Measuring patient-centered care: An updated systematic review of how studies define and report concordance between patients' preferences and medical treatments.Patient Educ Counsel. 2015; 98: 811-821
- Validation of preferences for life-sustaining treatment: Implications for advance care planning.Ann Intern Med. 1997; 127: 509-517
- Choices, values, and frames.Am Psychol. 1984; 39: 341-350
- Stability of end-of-life preferences: A systematic review of the evidence.JAMA Intern Med. 2014; 174: 1085
- The quality of Physician Orders for Life-Sustaining Treatment decisions: A pilot study.J Palliat Med. 2017; 20: 155-162
Article info
Publication history
Published online: November 24, 2020
Footnotes
This study was supported by the São Paulo Research Foundation (FAPESP) (grants: 2014/23966-0 to E.I.O.V., 2014/23997-3 to A.M.R., and 2016/25410-5 to J.J.C.R.), the Brazilian National Council for Scientific and Technological Development (CNPq) (grants: 164943/2015-3 to J.F.L.S. and 154995/2016-9 to A.F.N.), and by the Regional Medical Council of the State of São Paulo (CREMESP) (to M.A.M.). The funders did not play any role in the conception, design or conduction of the study, and were not involved neither in the analysis or interpretation of data nor in the preparation of the manuscript.
The authors declare no conflicts of interest.
Identification
Copyright
© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
