Dealing with ethical, legal and family Issues.
Dr. Susan Tolle, OHSU
Dr. Susan Tolle is a graduate of the Oregon Health & Science University. ..She completed her internal medicine residency at UC San Diego where she was also Chief Resident. …She founded and has directed the Oregon Health & Science University Center for Ethics in Health Care since 1989 and has shepherded its growth into a now internationally recognized ethics center with programs such as the Physicians Orders for Life-Sustaining Treatment (POLST) program and more recently the Oregon POLST Registry. Dr. Tolle is a Professor of Medicine and she holds the Cornelia Hayes Stevens Endowed Chair in Health Care Ethics. She is a practicing internist in the Division of General Medicine and Geriatrics. In 2014, she received the MacLean Prize in Clinical Medical Ethics.
Questions?Discussion
As I understand it, you created a system that’s known as Physician Orders for Life-Sustaining Treatment Program (“POLST”). For doing this you won the $50,000 MacLean Prize…I hope you don’t mind me mentioning that you distributed the prize to the various members of your medical team….
- What was it about this program that represented such an important breakthrough? Why is this, or why could it be, important to our listeners?
- How does the program work?
- How is it different from standard documents related to end of life treatment, such as “Living Will” and DNR directives?
- Does this exist only in Oregon? How about Washington and other states?
Patients in Oregon are less likely to receive intensive care and more likely to receive hospice care at end of life than patients in other states. You contend that this reflects the Physician Orders for Life-Sustaining Treatment Program (“POLST”) and efforts to honor patients’ preferences (from an article you authored with JM Teno and published in the NE Journal of Medicine, March 2017)
Here’s a summary of an article you co-authored, with Austin Lammers and Dana Zive, published in April, 2016, about the role of oncologist…
- Patients with cancer and oncology professional societies believe that advance care planning is important, but we know little of who actually has this conversation. Physician Orders for Life-Sustaining Treatment (POLST) forms can help to document these important conversations to ensure patients receive the level of treatment they want. We therefore sought to determine the specialty of those signing POLST forms for patients who died of cancer to better understand who is having this discussion with patients.
- Retrospective cohort study including all deaths due to cancer in Oregon between January 1, 2010, and December 31, 2011. Death certificates were matched to POLST forms in the Oregon POLST Registry, and the signing physician’s specialty was determined using the Oregon Medical Board’s database.
- A total of 14 979 people died of cancer in Oregon in 2010 to 2011. Of which, 6145 (41.0%) had at least 1 POLST form in the Registry. Oncology specialists signed 14.9% of POLST forms, compared to 53.7% by primary care, 15.3% by hospice/palliative care, 12.8% by advanced practice providers, and 2.7% by other specialists; 51.8% of oncology specialists did not sign a POLST form, whereas 12.5% completed 10 or more.
- Conclusion:
- Oncology specialists play a central role in caring for patients with cancer through the end of their lives, but not in POLST completion. Whether or not they actually sign their patients’ POLST forms, oncology specialists in the growing number of POLST states should integrate POLST into their goals of care conversations with patients nearing the end of life.
Here’s more information about the POLST program. This is from an article you wrote for the Journal of Pain and Symptom Management:
- The median interval between POLST completion and death was 6.4 weeks. Those dying of cancer had forms completed nearer death (median 5.1 weeks) than those with organ failure (10.6 weeks) or dementia (14.5 weeks; P < 0.001). More than 90% of final POLST forms indicated orders for no resuscitation and 65.1% listed orders for comfort measures only. Eleven percent of the sample had multiple registered forms during the two years preceding their death, with the form completed nearest to death more likely than earlier forms to have orders for no resuscitation and comfort measures only, although some later forms did have orders for more treatment.
Conclusion
- More than half of POLST forms were completed in the final two months of life. Cause of death influenced when POLST forms were completed. POLST forms changed in the two years preceding death, more frequently recording fewer life-sustaining treatment orders than the earlier form(s).
