TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents?

Physician Orders for Life-Sustaining Treatment (POLST) documents are medical orders intended to honor patient choice in the hospital and prehospital settings. We hypothesized that prehospital personnel will find these forms confusing.

The aim of this study was to determine whether POLST documents accord consensus in determining code status and treatment decisions among emergency medical services providers on the basis of an Internet survey. Consensus in this context reflects content clarity.

A statewide survey of Pennsylvania emergency medical technicians and paramedics was conducted from October 2013 to January 2014. Respondents supplied code status and treatment decisions for scenarios involving critically ill patients who present with POLST documents and then develop cardiac arrest. The gamut of combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and treatment (full, limited, comfort measures) was represented. Subgroup analysis was done using the Fisher exact test with a Bonferroni-corrected P = 0.017 as significant. We defined consensus as a supermajority of 95%.

Response to the survey was 18.4% (1069/5800). For scenarios specifying DNR and full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. With DNR and comfort measures specified, approximately 85% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Respondent age significantly affected response rates (P ≤ 0.004); prior POLST education had no impact. For most scenarios, responses failed to attain consensus, suggesting confusion in interpretation of the form.

In the Pennsylvania prehospital setting, POLST documents can be confusing, presenting a risk to patient safety. Additional research, standardized education, training, and/or safeguards are required to facilitate patient choice and protect safety.