School of Medicine and Health Sciences Poster Presentations

Title

Clarity or Confusion? A Comparative Analysis of the Usage of "Allow Natural Death" in State Polst Forms

Poster Number

189

Document Type

Poster

Publication Date

3-2016

Abstract

Introduction: Translating advance care planning discussions into actionable medical orders is a perennial challenge for providers caring for seriously ill patients. “Allow Natural Death” (AND) has been endorsed as an alternative to the traditional “Do Not Resuscitate” (DNR) order. Questions as to the clarity of its meaning exist however, and the frequency with which providers and institutions use AND is largely unknown. One place where AND terminology has been introduced is the Physician Orders for Life-Sustaining Treatment (POLST) form.

Methods: State POLST forms were analyzed to quantify and objectively characterize uses of AND orders. POLST forms for all states with existing programs were assessed for use of the phrase "Allow Natural Death." Incidences of AND were categorized with respect to surrounding language, instructions for medical interventions, and clinical circumstances dictating activation of the order. 45 states were identified as having POLST programs; 6 state forms were undergoing revision or had been withdrawn from public circulation at the time of study.

Results: 23 of the 39 state forms in active use (59%) utilized AND at least once as a medical order. 21 states (91%) used AND synonymously with DNR or Do Not Attempt Resuscitation, while 2 states (9%) used AND synonymously with Comfort Measures Only, an order dictating a broader set of limitations to medical interventions. Among states using AND synonymously with DNR, 16 (76%) explicitly prohibited defibrillation, while the remaining 5 (24%) did not address it. 17 AND/DNR orders (81%) were specified as being applicable to a person without pulse and respiration, with the remaining 4 (19%) applicable to one without pulse or respiration. "Allow Natural Death” orders are now employed by a majority of state POLST forms.

Conclusions: Our results confirm the wide variability in the meaning and use of AND orders, specifically with respect to the scope of medical interventions they address and the clinical conditions under which they are activated. Ambiguity continues to exist with this new terminology; we advise caution to institutions and providers considering use of AND language in medical orders, as the aforementioned discrepancies may contribute to misunderstandings and induce critical errors during emergent clinical situations.

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Creative Commons License
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Presented at: GW Research Days 2016

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Clarity or Confusion? A Comparative Analysis of the Usage of "Allow Natural Death" in State Polst Forms

Introduction: Translating advance care planning discussions into actionable medical orders is a perennial challenge for providers caring for seriously ill patients. “Allow Natural Death” (AND) has been endorsed as an alternative to the traditional “Do Not Resuscitate” (DNR) order. Questions as to the clarity of its meaning exist however, and the frequency with which providers and institutions use AND is largely unknown. One place where AND terminology has been introduced is the Physician Orders for Life-Sustaining Treatment (POLST) form.

Methods: State POLST forms were analyzed to quantify and objectively characterize uses of AND orders. POLST forms for all states with existing programs were assessed for use of the phrase "Allow Natural Death." Incidences of AND were categorized with respect to surrounding language, instructions for medical interventions, and clinical circumstances dictating activation of the order. 45 states were identified as having POLST programs; 6 state forms were undergoing revision or had been withdrawn from public circulation at the time of study.

Results: 23 of the 39 state forms in active use (59%) utilized AND at least once as a medical order. 21 states (91%) used AND synonymously with DNR or Do Not Attempt Resuscitation, while 2 states (9%) used AND synonymously with Comfort Measures Only, an order dictating a broader set of limitations to medical interventions. Among states using AND synonymously with DNR, 16 (76%) explicitly prohibited defibrillation, while the remaining 5 (24%) did not address it. 17 AND/DNR orders (81%) were specified as being applicable to a person without pulse and respiration, with the remaining 4 (19%) applicable to one without pulse or respiration. "Allow Natural Death” orders are now employed by a majority of state POLST forms.

Conclusions: Our results confirm the wide variability in the meaning and use of AND orders, specifically with respect to the scope of medical interventions they address and the clinical conditions under which they are activated. Ambiguity continues to exist with this new terminology; we advise caution to institutions and providers considering use of AND language in medical orders, as the aforementioned discrepancies may contribute to misunderstandings and induce critical errors during emergent clinical situations.