Are Physician Orders for Life-Sustaining Treatments the Answer to the End-of-Life Care Quality Conundrums in Cancer Care?

Pedraza et al1 present compelling results from their study in which physician orders for life-sustaining treatments (POLST) forms versus traditional advance directives were evaluated with respect to their benefits in limiting aggressive care at the end of life for patients with cancer. Their findings were impressive in that patients with advanced cancer who completed POLST forms were 2.33 times more likely to have an out-of-hospital death and 2.69 times more likely to be admitted to hospice compared with patients who completed traditional advance directives.1 Given that both out-of-hospital death and appropriate, timely use of hospice services are viewed as aspirational measures of quality, these findings have valuable implications for cancer care providers. Pedraza et al1 identified patients with advanced cancer for whom POLST completion—by an affirmative response to the question, “Would I be surprised if this patient died in the next year?”—was appropriate. Moss et al2 have demonstrated that this question has some prognostic validity in identifying patients for whom palliative care services are appropriate. Whereas this question may be an appropriate trigger for POLST completion, ongoing discussions regarding a patient's care goals and preferences for advanced treatments must still occur much earlier and longitudinally in the process of patient-centered, comprehensive cancer care. In this study, in addition to being associated with higher rates of out-of-hospital death and hospice utilization, patients in the POLST group were noted to have completed the forms much closer to the time of death (mean, 3.0 months before death) compared with advance directive completion, which occurred much earlier in the care trajectory (mean, 8.6 months before death).1 This is a crucial finding that suggests that discussion of care goals and reflection on patient values and care preferences seems to be happening at an earlier point in the care process. The finding of 82% of clinicians who completed POLST forms were primary care physicians, and that primary care physicians accounted for 54% of document completion overall, is encouraging. I agree with the authors that these figures are laudable in light of the value of ongoing continuity with primary care providers. To this end, there does not seem to be a divergence of care to either oncologists or palliative care physicians at the end of life. Not surprisingly, palliative care providers had the highest frequency of POLST completion (16.1 forms per clinician v 2.0 and 3.2 forms per primary care physician and oncologist,