Due to incomplete, or sometimes contradictory, end-of-life care forms, aged patients might be getting more aggressive treatment than they actually want, according to a small study from New York state. This can lead to difficulties interpreting the wishes of frail, elderly, or terminally ill patients who are unable to speak for themselves and could result in wishes being inadvertently violated by well-meaning doctors.
In Brief: End-of-Life Care
The study focuses on Physicians’ Orders for Life Sustaining Treatments (POLST), which are the forms that can be filled out to specify what interventions are or are not desired when faced with a medical situation. The forms contain broad specifications such as “do-not-resuscitate” to more particular matters such as whether the person wishes to be given an IV or antibiotics.
The study examined 100 MOLST (New York State’s version of POLST) forms from patients arriving at the emergency department. The forms were analyzed for incomplete sections and any contradictory statements.
It was found that 69% of the forms had at least one section left blank and that contradictions in what was specified were seen in 14% of the forms. A contradiction, for the purposes of the study, would be something like marking down orders for CPR while also indicating choices like “limited intervention only” or “do not intubate”. Another example would be marking a selection of “no intervention” but also saying they do want a breathing tube.
What This Means
Emergency medical providers tend to default to the most aggressive treatment unless a POLST form says otherwise. This is what happens if a section is left blank. It is unclear how contradictory statements are resolved, but it is probable that it resulted in, at least some cases, a patient getting treatment they did not in fact wish for.
The findings highlight a need for additional clarification and communication between patients and doctors when these forms are being filled out. How this is accomplished is not specified directly and the exact nature of the approach most likely differs from case to case. For instance, sometimes it might help if the doctor notices a contradictor and alerts the patient so they can get clarification. In other cases, it could be that the patient does not fill in a section because they do not understand what it means and need additional explanation.
With both aged and terminally-ill patients and doctors more aware of the consequences of these forms and the need for clarity, hopefully end-of-life care will improve as a result.
Clemency, B., “Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care,” Journal of Post-Acute and Long-Term Care Medicine, 2016; http://dx.doi.org/10.1016/j.jamda.2016.07.032