Unwanted End-of-Life Care Increases Patient Emotional Distress

The use of Physician Orders for Life-Sustaining Treatment (POLSTs) among patients with chronic illnesses is intended to curb administration of unwanted or unnecessary end-of-life care. According to a recent study published in JAMA, treatment-limiting POLSTs were significantly associated with lower rates of intensive care unit (ICU) admissions among patients with life-limiting conditions compared with patients who had full-treatment POLSTs. However, researchers found 38% of patients with treatment-limiting POLSTs still received intensive care that was potentially discordant with their preferences.

The administration of potentially unwanted intensive care could lead to a high burden of unrelieved physical symptoms and emotional distress in patients. In addition, researchers note that intensive care, including mechanical ventilation, “accounts for a disproportionate amount of healthcare expenditures within the last years of life,” emphasizing the importance of reducing overtreatment.

According to authors, many patients with chronic illnesses prioritize symptom relief over life extension. “Treatment-limiting POLSTs have been associated with less in-hospital death, hospitalization, and unwanted cardiopulmonary resuscitation (CPR) and with a low incidence of intensive care in nursing home residents,” they said. Less research has been conducted on POLST-discordant care in other populations.

Researchers conducted a retrospective cohort study of decedents who died between January 2010 and December 2017. Eligible patients must have completed a POLST, had a chronic illness, and been admitted to a hospital 6 months or less before their death. Data from 1818 patients were analyzed in the study, and the patients were categorized into 3 groups based on if they preferred to receive comfort measures only (22%), limited additional interventions (42%), or full treatment (36%) at the end of their lives.

Intensive care was defined in 2 ways. Patients must have either been admitted to the ICU or received any of the following life-sustaining treatments: mechanical ventilation, vasoactive infusions, new dialysis, or CPR. For limited-interventions POLSTs, “any ICU admission, except admissions for symptom management only and admissions solely for the delivery of noninvasive ventilation without additional life-sustaining treatments,” were considered POLST-discordant, researchers said.

Results showed that patients admitted to the ICU for traumatic brain injury in the comfort-only and limited-intervention groups were significantly more likely to receive POLST-discordant care compared with patients without traumatic brain injuries. The remaining cohort of patients suffered from cancer, congestive heart failure, dementia, or other chronic illnesses.

Specifically, the study found the incidence of ICU admission was 31% for patients with comfort-only POLSTs, 46% for limited-interventions orders, and 62% for full-treatment orders. Overall, patients with comfort-only or limited- interventions POLSTs were “significantly less likely to be admitted to the ICU…and were also significantly less likely to receive life-sustaining treatments.”

However, the researchers also found the “incidence of POLST-discordant intensive care was 30% (95% CI, 26%-35%) in the comfort-only group and 41% (95% CI, 38%-45%) in the limited-intervention group, for a combined incidence of 38% (95%CI, 35%-40%)." Of those with treatment-limiting POLSTs, 18% received mechanical ventilation, vasoactive infusions, dialysis, or CPR. These findings point to areas for improvment in POLST administration and adherence.

The study yielded the additional findings:

• Dementia was associated with significantly lower risk of POLST-discordant care in patients with comfort-only POLSTs
• Cancer was associated with a significantly lower risk of POLST-discordant intensive care
• Older age was independently associated with a significant decrease in POLST-discordant care among patients with limited-interventions POLSTs but not among those with comfort-only POLSTs
• No significant association existed between POLST-discordant intensive care and date of death over the 8-year study period

Researchers note their findings support the hypothesis that patients suffering from less predictable prognostic trajectories may receive more intense and POLST-discordant care near the end of their lives.

Administering end-of-life care can be difficult for caregivers and physicians, as the presence of certain conditions may ethically compel different treatment courses than originally outlined in POLSTs. But “for patients who do not want aggressive treatments near the end of life, unwanted intensive care may incur physical, emotional, and financial costs while providing little value,” the researchers said.

To avoid these outcomes, and to establish advanced care planning, Congress passed the Patient Self-Determination Act of 1990. POLSTs, living wills, and advance directives can all mitigate adverse consequences, but each method faces significant challenges.

“[The protocals] depend on predictions made at a single point in time to determine what will happen at a future time,” explained the authors in an editorial on the topic. Changes in clinical scenarios over time, assuming patient preferences will remain the same, and prognostic uncertainty all compound the issue of selecting and enforcing the best end-of-life care.

Even when patients make it clear they wish to receive full treatment, some practices can bring more challenges than benefits. “While receipt of these therapies would be considered POLST-concordant care, clinicians sometimes object to providing care that they perceive will be unbeneficial or even harmful,” the editorial authors noted. “These conflicts between clinicians and patients or their surrogates are a common problem in ICU care and are seen as a major contributor to distress and frustration among clinicians.”

Despite the challenges that arise in providing sufficient end-of-life care, the authors of the study urge the importance of “reducing unwanted intensive care near the end of life." Doing so can reduce costs and, more importantly, improve patient-centered care.

Reference

Lee RY, Brumback LC, Sathitratanacheewin S, et al. Association of physician orders for life-sustaining treatment with ICU admission among patients hospitalized near the end of life [published online February 16, 2020]. JAMA. doi: 10.1001/jama.2019.22523.