Submitted by John Jesus, MD, Augusta Emergency Physicians
The emergency department is a setting in which medicine is practiced with limited time and information and where the patient-physician relationship is frequently stressed and fleeting. By themselves, these variables present significant challenges to patient-physician communication. This is especially true of the critically ill patient, who may or may not have the cognitive capacity to meaningfully participate in conversation.
DNR/DNI and Advance Directive documents have significant limitations:
Given the importance of self-determination plays in our basic understanding of ethically appropriate care, it would seem critical that any document used to capture end of life (EOL) preferences be accurate as possible. And yet, these documents assume patient preferences are stable over time, and do not appreciate that reversibility of patient illness and probability of survival heavily influence EOL treatment decisions.1,2 As a result, there have been significant discrepancies between patient EOL care preferences and their documented code status.3
Goals of Care:
Rather than approaching patients with questions about lifesaving interventions it has taken health care providers years of professional development to understand, we should instead focus on patient goals of care. Goals of care are frequently value based, and about which only the patient can be an expert. Once they are identified, health care providers can then make recommendations that optimally align hospital resources with patients’ needs.
The Virginia Physician Orders for Scope of Treatment (POST) form:
The Virginia POST form was created to address some of criticisms of DNR/DNI and AD documents.It breaks down EOL care interventions into categories of care (CPR, Medical interventions including intubation, antibiotics, and artificial hydration and nutrition) and then presents 2-3 corresponding choices.4 In so doing, the form requires a descriptions of patient goals, which are then paired with clear medical orders that are easily understood. The POST form serves as a middle ground between DNR/DNI documents which are often too specific to guide clinicians outside the avoidance of CPR and intubation and AD which are often too general to apply to specific medical situations. There is already evidence to suggest that POST forms better capture patient preference, and that the treatments provided more closely align with patients’ actual EOL care preferences.5–7 Our healthcare community would be doing our patients a great service by using these forms more frequently.
- Perkins HS. Controlling death: the false promise of advance directives. Ann Intern Med. 2007;147(1):51-57.
- Sehgal A, Galbraith A, Chesney M, Schoenfeld P, Charles G, Lo B. HOw strictly do dialysis patients want their advance directives followed? JAMA. 1992;267(1):59-63. doi:10.1001/jama.1992.03480010067026
- Jesus JE, Allen MB, Michael GE, et al. Preferences for resuscitation and intubation among patients with do-not-resuscitate/do-not-intubate orders. Mayo Clin Proc. 2013;88(7):658-665. doi:10.1016/j.mayocp.2013.04.010
- virginiapost. https://www.virginiapost.org/. Accessed December 4, 2018.
- Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc. 2010;58(7):1241-1248. doi:10.1111/j.1532-5415.2010.02955.x
- Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form. J Am Geriatr Soc. 2011;59(11):2091-2099. doi:10.1111/j.1532-5415.2011.03656.x
- Hickman SE, Nelson CA, Moss AH, et al. Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting. J Palliat Med. 2009;12(2):133-141. doi:10.1089/jpm.2008.0196