Provider's Orders for Life Sustaining Treatment

Aka: Provider's Orders for Life Sustaining Treatment, Do-Not-Resuscitate, DNR, POLST, Do Not Attempt Resuscitation, DNAR, DNI, Do Not Intubate, Code Status, Resuscitation Status

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II. Epidemiology

  1. More than 70% of older adults value quality of life over the extension of life duration
  2. More than 60% of adults rate bed-bound status or Mechanical Ventilation as worse than death
  3. Rubin (2020) JAMA Intern Med 180(6):907-9 [PubMed]
  4. Rubin (2016) JAMA Intern Med 176(10): 1557-9 [PubMed]

III. Types: Do Not Resuscitate (DNR) or Do Not Attempt Resuscitation (DNAR)

  1. Order prohibits Cardiopulmonary Resuscitation (CPR)
    1. Includes Do-Not-Intubate (DNI)
    2. Implementation varies by state (e.g. DNR as outpatient)
    3. Independent of Advance Directive
  2. Do Not Attempt Resuscitation (DNAR)
    1. Reflects the significant likelihood that Resuscitation will fail (for ROSC or survival to discharge)

IV. Types: Provider's Orders for Life Sustaining Treatment (POLST)

  1. Background
    1. Initially created in Oregon (1991), and has now expanded to 42 states as of 2018
  2. Indications
    1. Patients in Nursing Homes, Assisted Living, and Life Expectancy <12-24 months
  3. Description
    1. Single page portable doument that transfers between care systems
    2. Unlike abstract Advanced Directives, POLST is composed of actionable orders related to end of life
    3. Addresses multiple medical interventions (DNR/DNI, comfort care, Antibiotics, nutrition)
    4. Form travels with patient and copies sent to EMR, EMS, facilities and family

V. Management

  1. See Breaking Bad News
  2. See End-Of-Life Care
  3. See Discussing Terminal Illness
  4. See Preparatory Grief
  5. General Measures
    1. Use non-emergent encounters to discuss Resuscitation Status
    2. Best time to discuss Resuscitation Status is when the patient is at baseline status (before emergencies)
    3. Discuss Resuscitation as a procedural intervention with indications, contraindications and complications
  6. Emergent presentations
    1. Discuss life threatening condition with patient (if able) and with family members
      1. Explain current status (high risk of death), possible interventions and likely outcomes
      2. Regardless of intervention, patient status is tenuous, and no measure may absolutely ensure survival
    2. Frame the conversation as a time to quickly determine the best and most appropriate care for the patient
    3. Review pre-morbid functional status
    4. Consider how patient might feel if unable to ever care for themselves or do favorite activities
      1. What ability loss would make life not worth living?
      2. What states would the patient consider worse than death?
      3. How much would they would be willing to tolerate for extended life?
    5. Summarize conversation
      1. Patient's values and wishes, and unacceptable states (e.g. prolonged Mechanical Ventilation)
      2. Decision to make is regarding what type of intensive treatment to pursue
        1. Intensive treatment focused on comfort OR
        2. Intensive treatment focused on survival
    6. Make a recommendation based on patient wishes and values
      1. Support body to recover from illness excluding uncomfortable treatments, ensuring comfort and peace OR
      2. Support body to recover from illness including all intensive treatment

VI. References

  1. George and Ouchi in Herbert (2021) EM:Rap 21(5): 15-6
  2. Olson (2010) Park Nicollet Primary Care Update CME, Minneapolis, MN
  3. Orman and Abbott in Herbert (2018) EM:Rap 18(2): 13-4

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