Erik K. Fromme, MD, MCR

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When DNR is not the most important question Data
from the Oregon POLST Registry
Erik K. Fromme, MD, MCR Division of Hematology
Medical Oncology OHSU Center for Ethics in Health
Care Dana Zive, MPH Department of Emergency
Medicine Terri Schmidt, MD Department of
Emergency medicine OHSU Center for Ethics in
Health Care Elizabeth Olszewski, MPH Department
of Emergency Medicine Susan W. Tolle, MD Division
of General internal Medicine Geriatrics OHSU
Center for Ethics in Health CareOregon Health
Science University Portland, OregoN
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The next innovation
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POLST REGISTRY SUBMISSION AND ENTRY
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Submission mandatory

• Unless the patient wishes to opt out
• Thus the registry is both an innovation in
  advance care planning and a unique resource for
  understanding patient treatment preferences
  beyond resuscitation status.

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POLST REGISTRANTS PROPORTION OF POPULATION OVER
THE AGE OF 65 REPRESENTED IN THE REGISTRY AS OF
12/13/11 (2010 CENSUS DATA)
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Methods

• We analyzed all active forms signed and submitted
  from 12/3/09 to 12/2/10the Registrys first year
  of full operation.
• We calculated the prevalence of each POLST order
• We also calculated the probability of other
  orders depending on whether patients had a DNR
  order vs. an attempt CPR order.

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Results

• At the end of the first year there were 25,142
  active POLST forms
• 85.9 of POLST registrants were 65 or older (mean
  age 77.6 years, range 3 days to 106 years)
• 61 are female
• 40.4 resided in a rural area
• 37.9 of Oregonians live in rural areas, however
• 57.8 of Oregonians 65 and older live in rural
  areas
• POLST use is more prevalent in urban areas

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POLST Order prevalence

• CPR
• 72.1 of registrants had a DNR order
• 27.9 had an Attempt CPR order
• Scope of treatment
• 37.6 had orders for Limited Additional
  Interventions
• 36.3 had Comfort Measures Only
• 25.5 had Full Treatment
• Antibiotic preferences
• 46.7 had Use Antibiotics if Life Can Be
  Prolonged
• 44.5 had Determine Use or Limitation When
  Infection
• 7.3 had No Antibiotics Use Other Measures
• For Artificial Nutrition
• 56.8 had No Artificial Nutrition By Tube
• 33.2 had Defined Trial Period of Artificial
  Nutrition by Tube
• 7.3 had Long-term Artificial Nutrition by Tube

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If a patient has a POLST DNR Order (vs. an order
to Attempt CPR)
If CPR If DNR
Scope of Treatment order
- Full treatment 75.7 6.6
- Limited additional interventions 21.6 43.8
- Comfort measures only 2.7 49.6
Antibiotic Use order
- Use antibiotics 81.6 34.2
- Decide when infection occurs 17.8 55.7
- Do not use antibiotics 0.57 10.1
Artificial Nutrition Tube Order
- Long-term feeding tube 21.5 2.1
- Time-limited trial 60.5 24.0
- No feeding tube 17.9 73.9
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If a patient has a POLST DNR order, whats the
likelihood they would not want hospital transport?
If CPR If DNR Hospital?
Scope of Treatment order
- Full treatment 75.7 6.6 50.4 Yes
- Limited additional interventions 21.6 43.8 50.4 Yes
- Comfort measures only 2.7 49.6 49.6 No
Antibiotic Use order
- Use antibiotics 81.6 34.2
- Decide when infection occurs 17.8 55.7
- Do not use antibiotics 0.57 10.1
Artificial Nutrition Tube Order
- Long-term feeding tube 21.5 2.1
- Time-limited trial 60.5 24.0
- No feeding tube 17.9 73.9
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Resuscitation Resuscitation Medical interventions Medical interventions Medical interventions Artificial feeding tube Artificial feeding tube Artificial feeding tube Antibiotics Antibiotics Antibiotics
CPR DNR Full Treat LAI CMO Long term Trial No Yes Dec No
Prevalence 28 72 25 37 36 7 33 57 47 45 7
Odds 0.39 2.57 0.33 0.59 0.56 0.08 0.49 1.33 0.89 0.82 0.08
CPR - - 8.43 0.45 0.48 3.34 0.26 0.16 4.52 2.82 .071
DNR - - 0.21 1.3 1.71 0.27 1.53 1.97 0.58 0.62 1.40
Full Treat 11.29 0.089 - - - 3.74 3.41 0.099 6.03 0.21 0.65
LAI 0.49 2.05 - - - 0.34 1.27 0.97 1.10 1.20 0.15
CMO 0.053 18.72 - - - 0.16 0.15 7.27 0.26 2.03 2.89
Likelihood ratios gt 5 or lt 0.2
Likelihood ratios 2-5 or 0.2 to 0.5
Likelihood ratio between 0.5 and 2
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Conclusions

• Registry data demonstrate why clinicians should
  not use DNR status to infer more about patient
  wishes.
• Even for these mostly elderly patients
  extrapolating from a patient with a DNR order
  that they would want comfort measures only was
  almost exactly a 50/50 proposition.

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Implications

• Is it time we stopped making DNR the focus of
  Advance Care Planning?
• DNR is more about the health care system than
  about patient preferences
• DNR addresses only what to do at the very end of
  life but is a poor guide for what to do in the
  pre-arrest period
• Resuscitation is a procedure rather than a goal
  or value
• There is the tendency to determine code status
  and stop
• Patients with advanced illness and frailty may
  have low likelihoods of surviving resuscitation
• Scope of treatment gives better guidance in the
  pre-arrest period