Letting go: The influence of clinicians and proxy decision-makers on preferences for life-sustaining treatments.

摘要

Advance care directives and medical orders to limit life-sustaining treatments guide families and clinicians about the appropriate types of care for patients facing a life-threatening illness. Some studies have examined how clinicians might influence patient decisions and others have studied how proxy decisions differed from patients' in hypothetical scenarios. No known study has examined how clinician training and proxy decision-makers influence decisions about life-sustaining treatments in a severely ill patient population.;The Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST) conveys a patient's or proxy decision-maker's consent to administer or withhold treatments that could extend life. This study collected and analyzed data from 593 Massachusetts MOLSTs and their corresponding patient electronic health records at three hospitals. Proxy decision-makers signed 43% of the forms. Physicians signed 52% and nurse practitioners or physician assistants signed the remainder (48%); 50% of the clinicians were palliative care specialists.;Multivariate logistic regression analyses estimated the likelihood for All Treatment vs. Limit Treatment. A highly significant model (p<0.001; pseudo R2=0.436) demonstrated that proxy decision-makers were 58% less likely than patient decision-makers to choose All Treatment (OR=0.42; p<0.001). Other findings indicate that MOLST Forms signed by palliative care clinicians were more than 95% less likely to specify All Treatment than those signed by non-palliative care specialists (OR=0.02-0.05; p<0.001). Preferences were no different for MOLSTs signed by physicians vs. non-physicians. Other significant findings indicate that increasing severity of illness decreased the likelihood for specifying All Treatment. MOLST Forms for patients 60-79 years old were 53% (OR=0.47; p<0.05) less likely than those =80 years old were 79% (OR=0.22; p<0.001) less likely than the <60 group to want All Treatment..;High illness severity, proxy decision-makers, and increasing age independently decreased the likelihood for specifying All Treatment on a MOLST Form. Hospitals may want to use these attributes to prioritize patients who should complete a MOLST (or POLST) due to their increased likelihood for preferring to limit life-sustaining treatments. Patients nearing the end-of-life often receive medical care in multiple settings; MOLSTs or POLSTs can prevent unwanted treatments when patients are no longer able to communicate.