Erik K. Fromme, MD, MCRDivision of Hematology & Medical OncologyOHSU Center for Ethics in Health CareDana Zive, MPHDepartment of Emergency MedicineTerri Schmidt, MDDepartment of Emergency medicineOHSU Center for Ethics in Health CareElizabeth Olszewski, MPHDepartment of Emergency MedicineSusan W. Tolle, MDDivision of General internal Medicine & GeriatricsOHSU Center for Ethics in Health CareOregon Health & Science UniversityPortland, OregoN

When DNR is not the most important question: Data from the Oregon POLST Registry

TheOregonPOLST Registry

POLST REGISTRY SUBMISSION AND ENTRY

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.

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

Methods: We analyzed all active forms signed and submitted from

12/3/09 to 12/2/10—the Registry’s 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.

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

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

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%

If a patient has a POLST DNR order, what’s 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%

- 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%

Resuscitation Medical interventions

Artificial feeding tube

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 0.08CPR - - 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 > 5 or < 0.2Likelihood ratios 2-5 or 0.2 to 0.5Likelihood ratio between 0.5 and 2

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.

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