Citation

Ballou JH, Dewey E, Zonies DH. J. Trauma Acute Care Surg. 2019; 87(1): 153-160.

Affiliation

Division of Trauma, Surgical Critical Care, & Acute Care Surgery, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, L611, Portland, Oregon 97239.

Copyright

(Copyright © 2019, Lippincott Williams and Wilkins)

DOI

10.1097/TA.0000000000002321

PMID

31033897

Abstract

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) forms are portable medical orders documenting patient treatment preferences in an acute health decline. It is unclear how these forms are used in the management of elderly trauma patients.

METHODS: Patients age 65 and older presenting to a Level 1 trauma center were identified between 2012-2017. Hospital trauma registry and medical records were used to identify a pre-injury POLST and its acknowledgment by providers within 24 hours of arrival. A 1:1 propensity score matched sample was used to evaluate clinical outcomes based on the presence of a POLST limiting interventions with p<0.05 deemed significant.

RESULTS: 3,342 elderly trauma patients were identified. 192 (6%) had a POLST before the injury. Do Not Attempt Resuscitation (DNR) was listed in 154 patients (80%) and 79% desired to avoid the intensive care unit (ICU) with limited (54%) or comfort measures only (CMO, 25%). 107 (76%) of admitted POLST DNR patients had a DNR code status for the majority of their admission. 59 (58%) of the limited and 29 (60%) of the CMO patients were admitted to the ICU. Acknowledgment of a pre-injury POLST or code status was explicitly documented in 110 cases (57%). Propensity score analysis yielded a comparison sample of 288 patients. In the matched comparison, an acknowledged POLST with limitations was associated with a shorter ICU stay (1.7 vs. 2.8 days, p=0.008) but there was no difference in ICU admission (58% vs. 61%, p=0.69), total length of stay (3.8 vs. 4.8 days, p=0.08), or in-hospital mortality (13% vs. 8%, p=0.2).

CONCLUSION: Limited provider acknowledgment of pre-injury medical directives necessitates protocol development for the management of frail elderly trauma patients. When acknowledged, patients with a POLST limiting interventions had fewer ICU days without increased in-hospital mortality compared to similarly injured elderly patients.

Language: en