Determining Goal vs. POLST-Discordant Care among Hospitalized Patients: A Qualitative Study (RP117)

Outcomes 1. Integrating a qualitative approach, participants will understand the clinical context and depth of patient-family-/clinician communication influencing in-the-moment medical-care decision-making of patients with POLST for limited treatment/comfort measures.2. Participants will be able to demonstrate an understanding of the importance of high-quality communication around prognosis, risks/benefits/complications, expected recovery, and implications for quality of life during hospitalizations. Key Message Patients with POLST for limited-treatment/comfort measures sometimes receive intensive treatment not aligned with their POLST-preferences. We found most care received was goal-concordant with patients’ ‘in-the-moment’ preferences despite being POLST-discordant, which was influenced by clinician rescue mindset, lack of patient understanding illness trajectory, and decisional regret, implying need for high-quality communication. Importance POLST aim to ensure patients receive goal-concordant care. Despite POLST orders for treatment limitations or comfort measures only (CMO), patients sometimes receive intensive treatment that is POLST-discordant (i.e., not aligned with their documented preferences). Objective(s) To understand the clinical context in which patients with POLST orders for treatment limitations/CMO receive POLST-discordant care. Scientific Methods Utilized This was a secondary analysis of a retrospective study of patients presenting to an emergency department between April 2015-October 2016. Using the Oregon POLST Registry, we identified 1,769 patients with completed POLST, of which 848 selected limited treatment/CMO. From this cohort, 32 patients received intensive treatment (e.g., ICU admission, intubation/mechanical ventilation, hemodialysis). We performed thematic content analysis of documentation within the electronic health record to understand the context in which patients received POLST-discordant care. Results Mean age was 73 (SD=13); 31% had POLST orders for CMO. The majority of hospitalizations (78%) were related to acute illness requiring procedural interventions; within the context of such interventions, mechanical ventilation was the most common form of intensive treatment received (78%), followed by ICU admission (44%). Patients primarily consented themselves (72%). We identified several themes pertaining to the clinical context of POLST-discordant care, including: clinicians’ rescue mindset, lack of understanding of patients’ trajectory for recovery within the context of chronic illness, and decisional regret. Only 34% were discharged to their prior level of independence. Conclusion(s) Among patients with treatment limitations/CMO on POLST who present to the emergency department, POLST-discordant care may still represent goal-concordant care within the context of acute illness. However, miscommunication around goals and lack of consideration of patients’ acute illness within the broader context of their chronic illness trajectory may contribute to patient/family regret. Impact Patients’ preferences and goals should be assessed with high-quality communication around prognosis, risks/benefits/complications, expected recovery, and implications for quality-of-life during hospitalizations. Keywords Advanced care planning/shared decision making/Qualitative and mixed methods research