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What level of evidence do we need for POLST to use it ourselves, to advocate for wider usage, and for establishing POLST completion as a quality metric?\\xa0 The answers to these questions will vary.\\xa0 Reasonable people will disagree.\\xa0 And today, on our podcast, our guests disagree.\\xa0 Firmly.\\xa0 AND we are delighted that our guests modeled respectful disagreement.\\xa0 With no hard feelings.\\xa0 Respectful disagreement is in short supply these days.

Our guests today are Kelly Vranas, pulm crit care doc who published a systematic review in JAGS of the evidence for POLST (as well as other articles here, here,and here); Abby Dotson, who is Executive Director for National POLST and Director of the Oregon POLST registry; Karl Steinberg, geriatrician and palliative care doc and President of National POLST; and Scott Halpern, pulmonary critical care physician, bioethicists and palliative care researcher who was senior author of a Viewpoint in JAMA that was critical of the concept and evidence base for POLST (and argues little has changed).\\xa0

We had a full podcast, and I wasn\\u2019t able to give my take on the existing evidence for POLST, so I\\u2019ll write it here. I\\u2019m in the middle between Scott and Karl, where I suspect Kelly is, though we didn\\u2019t ask her explicitly.\\xa0 On the one hand, I agree with Scott that observational studies finding those who complete a POLST stating a preference for comfort oriented care and DNR are not go to the ICU says little about the effectiveness of POLST.\\xa0 Far more likely that those underlying preferences and values are what drove the findings than completion of the POLST form that codified the preferences into orders.\\xa0

On the other hand, I agree with Karl that the POLST has face validity, and anecdotal evidence is overwhelming.\\xa0 Certainly SOME of those avoided hospitalizations, CPR, and ICU stays were due to documentation of those orders in the POLST. The unanswered question is: HOW MUCH of the differences are due to the POLST?\\xa0 It\\u2019s not zero, as many of us have had cases in which we said, \\u201cThank god we completed that POLST, it clearly stopped X from happening.\\u201d But is it a tiny, meaningless, fraction?\\xa0 Or a substantial proportion?\\xa0 My guess is a small but meaningful fraction of differences in observational studies is due to completion of the POLST, though the majority of differences are due to underlying preferences and values. Is that fraction due to POLST large enough that we should design quality metrics around completion of POLST? Absolutely not. Do we need better evidence, preferably from an RCT of POLST vs no POLST? Yes. Caveat as well that RCTs should not be placed on pedestal as the only answer-\\xa0 often patients enrolled in RCTs do not represent real world patients - observational studies do.\\xa0 For a trial to have value, it should not exclude patients over age 80, or those with dementia, or patients residing in nursing homes.\\xa0 And it must be powered to detect a small but meaningful difference, not the same level of effect seen in observational studies. OK, I\\u2019ll step off my soap box.

Additional links mentioned in the podcast:

Recent\\xa0JGIM article on POLST in California nursing homes, hospitalization, and nursing home care

Karl\\u2019s\\xa0GeriPal post on appropriate use of POLST\\xa0

Enjoy!

-@AlexSmithMD