Erik K. Fromme, MD, MCR Division of Hematology & Medical Oncology

1. When DNR is not the most important question: Data from the Oregon POLST Registry Erik K. Fromme, MD, MCR Division of Hematology & Medical Oncology OHSU Center for Ethics in Health Care Dana Zive, MPH Department of Emergency Medicine Terri Schmidt, MD Department of Emergency medicine OHSU Center for Ethics in Health Care Elizabeth Olszewski, MPH Department of Emergency Medicine Susan W. Tolle, MD Division of General internal Medicine & Geriatrics OHSU Center for Ethics in Health CareOregon Health & Science University Portland, OregoN

2. The next innovation The Oregon POLST Registry

3. POLST REGISTRY SUBMISSION AND ENTRY

4. Submission mandatory • Unless the patient wishes to “opt out” • Thus the registry is both an innovation in advance care planning and a unique resource for understanding patient treatment preferences beyond resuscitation status.

7. POLST REGISTRANTS: PROPORTION OF POPULATION OVER THE AGE OF 65: REPRESENTED IN THE REGISTRY AS OF 12/13/11 (2010 CENSUS DATA)

8. Methods: • We analyzed all active forms signed and submitted from 12/3/09 to 12/2/10—the Registry’s first year of full operation. • We calculated the prevalence of each POLST order • We also calculated the probability of other orders depending on whether patients had a DNR order vs. an attempt CPR order.

9. Results: • At the end of the first year there were 25,142 active POLST forms • 85.9% of POLST registrants were 65 or older (mean age = 77.6 years, range 3 days to 106 years) • 61% are female • 40.4% resided in a rural area • 37.9% of Oregonians live in rural areas, however • 57.8% of Oregonians 65 and older live in rural areas • POLST use is more prevalent in urban areas

10. POLST Order prevalence • CPR: • 72.1% of registrants had a DNR order • 27.9% had an Attempt CPR order • Scope of treatment: • 37.6% had orders for Limited Additional Interventions • 36.3% had Comfort Measures Only • 25.5% had Full Treatment • Antibiotic preferences: • 46.7% had Use Antibiotics if Life Can Be Prolonged • 44.5% had Determine Use or Limitation When Infection • 7.3% had No Antibiotics Use Other Measures • For Artificial Nutrition: • 56.8% had No Artificial Nutrition By Tube • 33.2% had Defined Trial Period of Artificial Nutrition by Tube • 7.3% had Long-term Artificial Nutrition by Tube

11. If a patient has a POLST DNR Order (vs. an order to Attempt CPR)

12. If a patient has a POLST DNR order, what’s the likelihood they would not want hospital transport?

14. Conclusions • Registry data demonstrate why clinicians should not use ‘DNR’ status to infer more about patient wishes. • Even for these mostly elderly patients extrapolating from a patient with a DNR order that they would want comfort measures only was almost exactly a 50/50 proposition.

15. Implications • Is it time we stopped making ‘DNR’ the focus of Advance Care Planning? • DNR is more about the health care system than about patient preferences • DNR addresses only what to do at the very end of life but is a poor guide for what to do in the pre-arrest period • Resuscitation is a procedure rather than a goal or value • There is the tendency to determine code status and stop • Patients with advanced illness and frailty may have low likelihoods of surviving resuscitation • Scope of treatment gives better guidance in the pre-arrest period