Discussing resuscitation and levels of treatment with seriously ill and frail patients: Development and testing of a Danish POLST form

9.1 Background
Seriously ill or frail patients are often admitted to Danish hospitals without documentation of wishes for levels of treatment. This may lead to potentially burdensome, non-beneficial, and/or unwanted treatment.

9.2 Aim
This study aims to develop and test a Danish POLST form to enhance conversations between the patient and their treating physician about preferences for life-sustaining treatment and ensure the patient´s wishes are known and documented. The form is based on the US POLST form, and addresses patients´ preferences regarding cardiopulmonary resuscitation, medical treatment, and nutrition.

9.3 Methods
This multi-method study collects and analyses the results from POLST forms and questionnaires, followed up by semi-structured individual interviews. Quantitative data will be analysed using descriptive statistics. Thematic analysis is the analytic strategy for qualitative data. In the critical interpretation and discussion of the data, the results and themes derived from the study were further interpreted and discussed relative to relevant research and theories.

9.4 Results
9.4.1 Paper I
The Danish version of the POLST form was assessed as readable, understandable, and useful in obtaining and documenting Danish patients’ preferences for life-sustaining treatment by patients, relatives, physicians, and nurses. The majority patients did not want a resuscitation attempt, opted for selected treatments and no artificial nutrition. However, this needs to be confirmed in a larger scale study. To be able to discuss wishes for life-sustaining treatment, a manageable and clear document was perceived as important by the participants.

9.4.1 Paper II
The majority of seriously ill patients did not want a resuscitation attempt, opted for selected treatments and no artificial nutrition. The wishes for life-sustaining treatment were similar within age groups, genders, and locations, apart from younger patients being more in favour of a ‘full treatment’ and nursing home residents mostly preferring cardiopulmonary resuscitation. The majority of participants found that the Danish POLST was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree, and reported that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.

9.4.1 Paper III
Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making and documentation of the wishes was the main perceived challenges. The most important aspect of the conversation was strengthening patient autonomy.

9.5 Conclusion
The majority of participants found that the Danish POLST form was readable, understandable and useful for facilitating conversations and make decisions about life-sustaining treatment to either a high or very high degree. The POLST form facilitated an opportunity to openly discuss life-sustaining treatment.
The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments and no artificial nutrition. The wishes for life-sustaining treatment were similar within age groups, genders and locations, but with a tendency toward younger patients in favor of full treatment and nursing home residents more in favor of cardiopulmonary resuscitation. Relatives were considered key persons. The main challenges perceived were timing of the conversation and securing sufficient knowledge for shared decision-making and documentation of the wishes. The most important aspect of the conversation was strengthening patient autonomy.