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TRIAD VI: How Well Do Emergency Physicians Understand Physicians Orders for Life Sustaining Treatment (POLST) Forms?

Mirarchi, Ferdinando L. DO, FAAEM, FACEP*; Doshi, Ankur A. MD; Zerkle, Samuel W. DO*; Cooney, Timothy E. MS

doi: 10.1097/PTS.0000000000000165
Original Articles

Background Physician Orders for Life-Sustaining Treatment (POLST) documents are active medical orders to be followed with intention to bridge treatment across health care systems. We hypothesized that these forms can be confusing and jeopardize patient safety.

Objectives The aim of this study was to determine whether POLST documents are confusing in the emergency department setting and how confusion impacts the provision or withholding of lifesaving interventions.

Methods Members of the Pennsylvania chapter of the American College of Emergency Physicians were surveyed between September and October 2013. Respondents were to determine code status and treatment decisions in scenarios of critically ill patients with POLST documents who emergently arrest. Combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and levels of treatment (full, limited, comfort measures) were represented. Responses were summarized as percentages and analyzed by subgroup using the Fisher exact test. P = 0.05 was considered significant. We defined confusion in response as absence of consensus (supermajority of 95%).

Results Our response rate was 26% (223/855). For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%–84%) and 25% to 75% chose resuscitation. When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected “full code” and resuscitation. Physician age and experience significantly affected response rates; prior POLST education had no impact. In most scenarios depicted, responses reflected confusion over its interpretation.

Conclusions Significant confusion exists among members of the Pennsylvania chapter of the American College of Emergency Physicians regarding the use of POLST in critically ill patients. This confusion poses risk to patient safety. Additional training and/or safeguards are needed to allow patient choice as well as protect their safety.

From the *Department of Emergency Medicine, University of Pittsburgh Medical Center Hamot, Erie; †University of Pittsburgh School of Medicine, Pittsburgh; and ‡Basic Science Research, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania.

Correspondence: Ferdinando L. Mirarchi, DO, FAAEM, FACEP, Department of Emergency Medicine, University of Pittsburgh Medical Center Hamot, 201 State St, Erie, PA 16550 (e-mail:

The authors disclose no conflict of interest.

© 2015 by Lippincott Williams & Wilkins