End-of-Life Care and Patients’ Preferences

For at least two decades one approach to handling end-of-life care has been use of patient advance directives about the type of care they wish to receive and the entering of physician orders regarding that care.  Traditional advance directives and physician orders appear to have had little effect on spending near the end-of-life; spending which is often futile and inconsistent with patient preferences.  This appears to be because these directives and orders are often vague and it is hard to contemplate in advance all possible health conditions and an appropriate set of instructions for them.  The directives and orders are also not often available to all providers.  The Journal of the American Geriatric Society published the results of a study on a relatively new method of dealing with end-of-life care.   (Geriatrics Journal Article)

The Physician Orders for Life-Sustaining Treatment program utilizes a form with relatively detailed instructions regarding a patient’s preferences which is shared across facilities and providers.  Some version of the program is used in a large number of states.  The study sought to compare the POLST program with usual care.  The endpoints were ascertaining whether these patients were more likely to have orders reflecting their preferences and whether they received different end-of-life treatment than patients with usual care.  The study subjects were all nursing home residents.  As might be expected, more patients in the POLST program had standing orders reflecting end-of-life treatment than did patients with usual care, particularly if orders regarding cardio-pulmonary resuscitation were disregarded.  The pain and shortness-of-breath symptoms of both sets of subjects were assessed and treated in a consistent manner, indicating that the comfort needs of each group were handled similarly.

The POLST group, however, did receive significantly fewer life-sustaining treatments and especially had fewer visits to the hospital or emergency room near the end-0f-life.  Although not measured, it is likely that spending was therefore lower on this group.  These findings suggest that the program has a good effect on ascertaining patient preferences and ensuring that they are followed.  One of the most unfortunate aspects of the health reform outcome was that stronger requirements to discuss medical options with patients and ensure that they are documented, shared and followed were not included in the bill.  While following patient preferences about end-of-life care appears to lower costs, the most important aspect is respecting the dignity and autonomy of individuals in regard to medical treatment.