Goal-Concordant Care Among Seriously Ill Hospitalized Patients With Treatment Limitations on POLST: A Mixed-Methods...

Area of Science:

• Medical Ethics
• Palliative Care
• Health Services Research

Background:

• Physician Orders for Life-Sustaining Treatment (POLST) documents patient care preferences for serious illness.
• POLST-discordant care, where treatment contradicts documented preferences, is common but poorly understood.
• Investigating the context of POLST-discordant care is essential for aligning end-of-life care with patient goals.

Purpose of the Study:

• To examine the context of POLST-discordant care in seriously ill patients.
• To determine if POLST-discordant care represents goal-discordant care.
• To inform strategies for aligning end-of-life care with patient preferences.

Main Methods:

• Retrospective chart review of electronic medical records for patients with POLST limitations receiving high-intensity treatment.
• Inclusion criteria: POLST for limited treatment/comfort measures, presentation to ED, receipt of high-intensity treatment.
• Inductive/deductive content analysis of hospitalization documentation to identify decision-making themes.

Main Results:

• 32 patients with POLST limitations received POLST-discordant care, predominantly with cancer, cerebrovascular disease, or heart failure.
• Most patients (94%) had acute surgical diagnoses, underwent procedures, intubation (75%), or ICU admission (44%).
• Key themes: POLST-discordant care can be goal-concordant; clinician "Fix It" mindset; incomplete understanding of prognosis; challenges in POLST implementation.

Conclusions:

• POLST-discordant care in seriously ill patients can be goal-concordant despite high-intensity treatment.
• Clinician mindsets, communication, and understanding of clinical trajectory significantly impact treatment decisions.
• Effective interpretation of advance care planning documents in acute settings remains a challenge.