Concordance of Out-of-Hospital and Emergency Department Cardiac Arrest Resuscitation With Documented End-of-Life Choices in Oregon

Study objective

Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest.

Methods

This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED.

Results

There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated.

Conclusion

In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregon's POLST system to other methods of end-of-life order documentation.

Introduction

For patients with advanced illness and frailty, preferences and goals of care should guide resuscitation measures in the out-of-hospital and emergency department (ED) settings. Choices about medical management are complicated and personal and may be influenced by family support, religion, racial or ethnic background, and personal experience with hospice care.1, 2, 3, 4 Although advance directives are a widely available means for patients to document their preferences, they are not actionable medical orders and are often unavailable in emergency situations when it would otherwise significantly change management.5, 6 Complicated or unclear advance directives and living wills are easily misinterpreted in the out-of-hospital and ED setting, although formal evaluation of provider interpretation of these documents remains limited.7, 8 Expert recommendations to improve clear and direct documentation of patient decisions have been made since the 1990s; however, proper communication of these wishes remains elusive.9, 10 Since 1991, Oregon providers have used a standardized form, the Physician Orders for Life-Sustaining Treatments (POLST), to address and document end-of-life goals for patients with advanced illness or frailty. The POLST form is designed to be portable and actionable across treatment settings, including the home, nursing care facilities, or the hospital.¹¹ The form, signed in consultation with a medical provider, directs treating providers to provide or avoid cardiopulmonary resuscitation (CPR), antibiotics, feeding tubes, and transportation to the hospital through a series of clear and specific orders centered on goals of care. POLST orders allow documentation of more nuanced treatment preferences compared with standard do-not-resuscitate orders and are more direct than other end-of-life documentation formats.¹² POLST has found good acceptance with hospice facilities, emergency medical services (EMS) providers, and nursing facilities in Oregon.13, 14, 15

Editor's Capsule Summary

What is already known on this topic

Although end-of-life care can be guided by advance directives, it is unknown whether the relevant information is available to out-of-hospital and emergency department (ED) providers and whether it informs care.

What question this study addressed

When out-of-hospital and ED providers treat patients who have a Physician Orders for Life-Sustaining Treatments directive, is care within the described plan?

What this study adds to our knowledge

When emergency medical services and ED records were linked for 1,557 Oregon patients experiencing out-of-hospital cardiac arrest, only 82 patients had the directive in place. Most care was within the bounds of the directive when it existed.

How this is relevant to clinical practice

This approach to out-of-hospital directives shows promise in guiding care, but current use is sparse.

Although concordance of resuscitation measures with POLST documentation is strong in nursing and hospice facilities, the utility of the POLST program has not been studied among people living independently.¹⁶ A Washington study examining non-POLST hospital documentation among patients in residential facilities found frequent discordance of care delivery with documented wishes, suggesting that patients not living in health care facilities may be more at risk of miscommunicated or uncommunicated end-of-life decisions.¹⁰ Since 2010, the Oregon POLST program has implemented a call-in database accessible to EMS and hospital providers, with the goal of expeditiously and correctly relaying previous POLST documentation. Reliability of information obtained by telephone with signed POLST orders has been previously validated.¹⁷ As the POLST form is evaluated for expansion to other states, it is necessary to assess whether out-of-hospital and ED care provided in critical situations is concordant with POLST documentation recorded before those events.

We sought to evaluate the concordance of care provided by out-of-hospital and hospital providers with previously documented POLST orders in the setting of out-of-hospital cardiac arrest when 911 is called. Our primary outcome measures included resuscitation interventions at the scene, ED transport, and hospital admission. As a secondary aim, we reviewed POLST call center records to evaluate the effect of real-time access to electronic POLST forms on out-of-hospital and ED resuscitation.