E RIK K. F ROMME, MD, MCR D IVISION OF H EMATOLOGY & M EDICAL O NCOLOGY OHSU C ENTER FOR E THICS IN H EALTH C ARE D ANA Z IVE, MPH D EPARTMENT OF E MERGENCY M EDICINE T ERRI S CHMIDT, MD D EPARTMENT OF E MERGENCY MEDICINE OHSU C ENTER FOR E THICS IN H EALTH C ARE E LIZABETH O LSZEWSKI, MPH D EPARTMENT OF E MERGENCY M EDICINE S USAN W. T OLLE, MD D IVISION OF G ENERAL INTERNAL M EDICINE & G ERIATRICS OHSU C ENTER FOR E THICS IN H EALTH C ARE O REGON H EALTH & S CIENCE U NIVERSITY P ORTLAND, O REGO N When DNR is not the most important question: Data from the Oregon POLST Registry

The Oregon POLST Registry

POLST REGISTRY SUBMISSION AND ENTRY

S UBMISSION MANDATORY Unless the patient wishes to “opt out” Thus the registry is both an innovation in advance care planning and a unique resource for understanding patient treatment preferences beyond resuscitation status.

POLST REGISTRANTS: PROPORTION OF POPULATION OVER THE AGE OF 65: REPRESENTED IN THE REGISTRY AS OF 12/13/11 (2010 CENSUS DATA)

M ETHODS : We analyzed all active forms signed and submitted from 12/3/09 to 12/2/10—the Registry’s first year of full operation. We calculated the prevalence of each POLST order We also calculated the probability of other orders depending on whether patients had a DNR order vs. an attempt CPR order.

R ESULTS : At the end of the first year there were 25,142 active POLST forms 85.9% of POLST registrants were 65 or older (mean age = 77.6 years, range 3 days to 106 years) 61% are female 40.4% resided in a rural area 37.9% of Oregonians live in rural areas, however 57.8% of Oregonians 65 and older live in rural areas POLST use is more prevalent in urban areas

POLST O RDER PREVALENCE CPR: 72.1% of registrants had a DNR order 27.9% had an Attempt CPR order Scope of treatment: 37.6% had orders for Limited Additional Interventions 36.3% had Comfort Measures Only 25.5% had Full Treatment Antibiotic preferences: 46.7% had Use Antibiotics if Life Can Be Prolonged 44.5% had Determine Use or Limitation When Infection 7.3% had No Antibiotics Use Other Measures For Artificial Nutrition: 56.8% had No Artificial Nutrition By Tube 33.2% had Defined Trial Period of Artificial Nutrition by Tube 7.3% had Long-term Artificial Nutrition by Tube

If a patient has a POLST DNR Order (vs. an order to Attempt CPR) If CPRIf DNR Scope of Treatment order - Full treatment75.7%6.6% - Limited additional interventions21.6%43.8% - Comfort measures only2.7%49.6% Antibiotic Use order - Use antibiotics81.6%34.2% - Decide when infection occurs17.8%55.7% - Do not use antibiotics0.57%10.1% Artificial Nutrition Tube Order - Long-term feeding tube21.5%2.1% - Time-limited trial60.5%24.0% - No feeding tube17.9%73.9%

If a patient has a POLST DNR order, what’s the likelihood they would not want hospital transport? If CPRIf DNRHospital? Scope of Treatment order - Full treatment75.7%6.6%50.4% Yes - Limited additional interventions21.6%43.8% - Comfort measures only2.7%49.6%49.6% No Antibiotic Use order - Use antibiotics81.6%34.2% - Decide when infection occurs17.8%55.7% - Do not use antibiotics0.57%10.1% Artificial Nutrition Tube Order - Long-term feeding tube21.5%2.1% - Time-limited trial60.5%24.0% - No feeding tube17.9%73.9%

Resuscitation Medical interventions Artificial feeding tube Antibiotics CPRDNR Full Treat LAICMO Long term TrialNoYesDecNo Prevalence 28%72%25%37%36%7%33%57%47%45%7% Odds CPR DNR Full Treat LAI CMO Likelihood ratios > 5 or < 0.2 Likelihood ratios 2-5 or 0.2 to 0.5 Likelihood ratio between 0.5 and 2

C ONCLUSIONS Registry data demonstrate why clinicians should not use ‘DNR’ status to infer more about patient wishes. Even for these mostly elderly patients extrapolating from a patient with a DNR order that they would want comfort measures only was almost exactly a 50/50 proposition.

I MPLICATIONS Is it time we stopped making ‘DNR’ the focus of Advance Care Planning? DNR is more about the health care system than about patient preferences DNR addresses only what to do at the very end of life but is a poor guide for what to do in the pre-arrest period Resuscitation is a procedure rather than a goal or value There is the tendency to determine code status and stop Patients with advanced illness and frailty may have low likelihoods of surviving resuscitation Scope of treatment gives better guidance in the pre- arrest period