March 26, 2024

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

Susan Hickman

Published in Journal of the American Medical Directors Association. Here is a link to the article.

Regenstrief Institute author: Susan Hickman, PhD.


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.

Integrative review.

Setting and Participants
Not applicable.

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.

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.


Elizabeth E. Umberfield PhD, RN ab, Matthew C. Fields BSN, RN cd, Rachel Lenko PhD, RN e, Teryn P. Morgan BS fg, Elissa Schuler Adair PhD h, Erik K. Fromme MD ij, Hillary D. Lum MD, PhD k, Alvin H. Moss MD lm, Neil S. Wenger MD, MPH n, Rebecca L. Sudore MD op, Susan E. Hickman PhD cdq


aDivision of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA
bDepartment of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA
cSchool of Nursing, Indiana University, Indianapolis, IN, USA
dResearch in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
eDepartment of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
fCenter for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA
gDepartment of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
hLines for Life, Portland, OR, USA
iDepartment of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
jAriadne Labs at Brigham and Women’s Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
kDivision of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
lCenter for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA
mDivisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
nDivision of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
oDivision of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
pSan Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
qIndiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA

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