Goal-concordant care among seriously ill hospitalized patients with treatment limitations on POLST: A mixed-methods study Journal Article


Authors: Vranas, K. C.; Singh, R.; Shenk, J. L.; Lin, A. L.; Lee, B.; Slatore, C. G.; Rosa, W. E.; Sullivan, D. R.
Article Title: Goal-concordant care among seriously ill hospitalized patients with treatment limitations on POLST: A mixed-methods study
Abstract: Background: POLST enables patients with serious illness to document care preferences. POLST-discordant care is common, but little is known about the context in which this occurs and whether it represents goal-discordant care. We sought to examine the context in which seriously ill patients receive POLST-discordant care and inform efforts to align end-of-life care with patients' preferences. Methods: We performed a chart review of the electronic medical records of patients with POLST preferences for limited treatment or comfort measures who presented to the emergency department and received high-intensity treatment (i.e., POLST-discordant care) between April 2015 and October 2016 at a quaternary medical center. High-intensity treatment was defined using a validated set of measures. We used inductive/deductive content analysis to analyze documentation pertaining to patients' hospitalizations and identify themes related to medical decision making and goals-of-care discussions. Results: A total of 32 patients with treatment limitations on POLST received POLST-discordant care. Cancer, cerebrovascular disease, and heart failure were the most prevalent comorbidities. Of these, 30 patients (94%) presented with acute surgical diagnoses and underwent ≥ 1 procedure; 24 (75%) underwent intubation/mechanical ventilation, and 14 (44%) were admitted to the ICU. We identified four themes related to the receipt of POLST-discordant care: (1) POLST-discordant care may represent goal-concordant care; (2) “Fix It” mindset among clinicians contributes to high-intensity treatment; (3) Incomplete understanding of clinical trajectory may contribute to non-beneficial care; and (4) Challenges in POLST implementation limit its utility to address context-specific medical decision-making. Conclusions: This mixed-methods study of seriously ill patients with treatment limitations on POLST provides context for receipt of “POLST-discordant care” in the acute-care setting and reveals how such treatment may still represent goal-concordant care. Our findings reveal complexities when considering goal-concordant but potentially non-beneficial care among seriously ill patients, and demonstrate the impact of clinicians' mindsets and communication on delivery of high-intensity treatment. Finally, our study highlights the nuances of medical decision-making and the persistent challenge of interpreting advance-care planning documents in acute-care settings. © 2025 The American Geriatrics Society.
Keywords: end-of-life care; treatment intensity; mixed-methods study; goal-concordant care; portable orders for life-sustaining (polst) treatment
Journal Title: Journal of the American Geriatrics Society
ISSN: 0002-8614
Publisher: Wiley Blackwell  
Publication status: Online ahead of print
Date Published: 2025-07-14
Online Publication Date: 2025-07-14
Language: English
DOI: 10.1111/jgs.70014
PROVIDER: scopus
PUBMED: 40660462
DOI/URL:
Notes: Article -- Source: Scopus
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  1. William   Rosa
    220 Rosa