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Background: Portable Orders for Life-Sustaining Treatment (POLST) are increasingly utilized to assist patients approaching the end of life in documenting goals of care. We evaluated the association of POLST, resource utilization, and costs to 1 year among injured older adults requiring emergency services.Methods: This was a retrospective cohort of injured older adults ≥65 years with continuous Medicare fee-for-service coverage transported by emergency medical services (EMS) in 2011 across 4 counties in Oregon. Data sources included EMS, Medicare claims, vital statistics, and state POLST, inpatient and trauma registries. Outcomes included hospital admission, receipt of aggressive medical interventions, costs, and hospice use. We matched patients on patient characteristics and comorbidities to control for bias.Results: We included 2116 patients of which 484 (22.9%) had a POLST form prior to 911 contact. Of POLST patients, 136 (28.1%) had orders for full treatment, 194 (40.1%) for limited interventions, and 154 (31.8%) for comfort measures. There were no significant associations for care during the index event. However, in the year after the index event, patients with care limitations had higher adjusted hospice use (limited interventions OR 1.7 [95% CI: 1.2-2.6]; comfort OR, 2.0 [95% CI: 1.3-3.0]) and lower adjusted post-discharge costs (no POLST, $32,399 [95% CI: 30,041-34,756]; limited interventions, $18,729 [95% CI: 12,913-24,545]; and comfort $15,593 [95% CI: 12,091-19,095]). There were no significant associations for all other outcomes.Conclusions: Care limitations specified in POLST forms among injured older adults transported by EMS are associated with increased use of hospice and decreased costs to 1 year. [ABSTRACT FROM AUTHOR]

1. Integrating a qualitative approach, participants will understand the clinical context and depth of patient-family-/clinician communication influencing in-the-moment medical-care decision-making of patients with POLST for limited treatment/comfort measures. 2. Participants will be able to demonstrate an understanding of the importance of high-quality communication around prognosis, risks/benefits/complications, expected recovery, and implications for quality of life during hospitalizations. Patients with POLST for limited-treatment/comfort measures sometimes receive intensive treatment not aligned with their POLST-preferences. We found most care received was goal-concordant with patients' 'in-the-moment' preferences despite being POLST-discordant, which was influenced by clinician rescue mindset, lack of patient understanding illness trajectory, and decisional regret, implying need for high-quality communication. POLST aim to ensure patients receive goal-concordant care. Despite POLST orders for treatment limitations or comfort measures only (CMO), patients sometimes receive intensive treatment that is POLST-discordant (i.e., not aligned with their documented preferences). To understand the clinical context in which patients with POLST orders for treatment limitations/CMO receive POLST-discordant care. This was a secondary analysis of a retrospective study of patients presenting to an emergency department between April 2015-October 2016. Using the Oregon POLST Registry, we identified 1,769 patients with completed POLST, of which 848 selected limited treatment/CMO. From this cohort, 32 patients received intensive treatment (e.g., ICU admission, intubation/mechanical ventilation, hemodialysis). We performed thematic content analysis of documentation within the electronic health record to understand the context in which patients received POLST-discordant care. Mean age was 73 (SD=13); 31% had POLST orders for CMO. The majority of hospitalizations (78%) were related to acute illness requiring procedural interventions; within the context of such interventions, mechanical ventilation was the most common form of intensive treatment received (78%), followed by ICU admission (44%). Patients primarily consented themselves (72%). We identified several themes pertaining to the clinical context of POLST-discordant care, including: clinicians' rescue mindset, lack of understanding of patients' trajectory for recovery within the context of chronic illness, and decisional regret. Only 34% were discharged to their prior level of independence. Among patients with treatment limitations/CMO on POLST who present to the emergency department, POLST-discordant care may still represent goal-concordant care within the context of acute illness. However, miscommunication around goals and lack of consideration of patients' acute illness within the broader context of their chronic illness trajectory may contribute to patient/family regret. Patients' preferences and goals should be assessed with high-quality communication around prognosis, risks/benefits/complications, expected recovery, and implications for quality-of-life during hospitalizations. Advanced care planning/shared decision making/Qualitative and mixed methods research [ABSTRACT FROM AUTHOR]

Bupropion is an aminoketone antidepressant. A major concern in bupropion toxicity is seizure activity, which can occur up to 24 h from ingestion. It is difficult to predict which patients will have seizures. The purpose of this study is to identify clinical features associate with seizure after bupropion overdose. We searched the Toxicology Investigators Consortium registry for a cases of poisoning by bupropion between January 1, 2014 and January 1, 2017 in patients aged 13–65. Demographic variables and clinical features were compared between patients who did and did not experience a seizure and presented as unadjusted odds ratios (OR). Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) between clinical features and seizures. There were 256 cases of bupropion overdose remaining after inclusion/exclusion criteria were applied. Clinical features associated with seizure were QTc >500 (OR = 3.4, 95% CI: 1.3–8.8, p = 0.012), tachycardia (p > 140) (OR = 1.9, 95% CI: 1–3.561, p = 0.05), and age 13–18 years (2.4, 95% CI: 1.3–4.3, p = 0.005). The mean QTc value for patients experiencing a seizure was 482 ms (N = 95 IQR: 59 ms) versus 454 ms (N = 103, IQR: 43) in patients who did not experience seizure, however, it was not possible to identify a QTc cutoff with sensitivity or specificity to predict seizures. Based on our analysis of data from the ToxIC registry, age (13–18), tachycardia (p > 140) and QTc >500 ms are associated with seizures in bupropion overdose; however, a specific QTc value may not be a useful predictor of seizures. [ABSTRACT FROM AUTHOR]