An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go?

Elizabeth E Umberfield; Matthew C Fields; Rachel Lenko; Teryn P Morgan; Elissa Schuler Adair; Erik K Fromme; Hillary D Lum; Alvin H Moss; Neil S Wenger; Rebecca L Sudore; Susan E Hickman

doi:10.1016/j.jamda.2024.01.009

An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go?

J Am Med Dir Assoc. 2024 Apr;25(4):557-564.e8. doi: 10.1016/j.jamda.2024.01.009. Epub 2024 Feb 21.

Authors

Affiliations

¹ Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA. Electronic address: Umberfield.Elizabeth@mayo.edu.
² School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.
³ Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA.
⁴ Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA.
⁵ Lines for Life, Portland, OR, USA.
⁶ Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.
⁷ Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
⁸ Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA.
⁹ Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
¹⁰ Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
¹¹ School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA.

PMID: 38395413
PMCID: PMC10996838 (available on 2025-04-01)
DOI: 10.1016/j.jamda.2024.01.009

Abstract

Objectives: POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research.

Design: Integrative review.

Setting and participants: Not applicable.

Methods: We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization.

Results: Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified.

Conclusions and implications: Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.

Keywords: Portable medical orders; advance care planning; patient outcome assessment; review [publication type].

Publication types

Review

MeSH terms

Advance Care Planning*
Documentation
Humans
Prospective Studies
Resuscitation Orders

Abstract

Publication types

MeSH terms

Grants and funding