You are working at a community trauma center when an elderly male is brought to the ED after being struck by a car.  The patient is complaining of right sided chest pain and is in respiratory distress. He has a patent airway, is breathing spontaneously and is normotensive.  He is confused and not oriented to place or time. A chest x-ray does not reveal a pneumothorax, but does reveal 5 contiguous rib fractures. The patient is likely to require intubation due to the increased work of breathing.  You review the patient's chart and note that he has a POLST on file indicating a DNR/DNI status as well as identifying his daughter as a medical power of attorney who may override the POLST. A nurse lets you know the patient’s family has arrived.  You wonder how the presence of the POLST form will influence your conversation with the family.

Advanced directives and POLSTs are valuable documents which allow patients to express their wishes regarding resuscitative care.  A recent study from the University of Washington evaluated the association of POLST orders with ICU care (defined as intubation/mechanical ventilation, vasopressor administration, CPR) given to patients near the end of life.  This cohort of patients included those who were hospitalized in the last 6 months of life and had a POLST on file prior to the hospitalization. The study found that patients with a POLST indicating comfort care only or only accepting limited medical interventions were much less likely to be admitted to the ICU in the last 6 months of life.  However, 38% of patients received POLST discordant care. Patients who presented following traumatic injuries were much more likely to have care which was not consistent with their POLST on file. This is not to say the care delivered was inappropriate or harmful. The patient’s family may have requested ICU interventions to alleviate symptoms or afford additional time for family to gather.  The authors note this discordance may be due to the sudden nature of traumatic injuries as opposed to medical pathology which affords the patient and family time to prepare for the patient’s death over a longer period.

POLSTs should be reviewed at each transition of care and at regular intervals.  However, a POLST form may not entirely capture the patient’s priorities at the end of life in terms of family presence, symptom management, or other important issues which deserve consideration.  This patient’s sudden, traumatic injury with resulting respiratory failure may cause understandable, significant emotional distress among his family. The emergency medicine physician conducting a goals of care conversation with this patient’s family should raise the existing POLST form, but also approach the topic of intubation gently and collaboratively with his family in order to determine the most appropriate course of action.

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. JAMA. February 2020. doi:10.1001/jama.2019.22523.