Thursday, October 30, 2014

Planning with POLST

POLST, or Physician Orders for Life-Sustaining Treatment, is an approach to end-of-life care that encourages discussions between patients and their health care providers. The goal of POLST is to enable patients to choose the treatment they want or do not want, and to ensure that those preferences are honored.

With POLST, patients discuss with their doctors their diagnosis, prognosis, and treatment alternatives, including the benefits and burdens of life-sustaining treatment, as well as the patients’ values, beliefs, and goals for care. Based on these conversations, patients (or their health care agents) and their health care providers complete a POLST form, which documents the patient’s wishes with respect to end-of-life care. The POLST form is signed by the patient’s health care provider and becomes a part of the patient’s medical record. The form serves as the patient’s standing medical orders for that patient’s particular treatment preferences in the event of a medical emergency.

On a POLST form, the patient selects (1) whether or not they wish to be given CPR; (2) what degree of medical intervention they want in an acute situation: “comfort measures only,” “limited additional interventions,” or “full treatment;” and (3) the extent to which they want artificial nutrition to be administered, if at all. The POLST form is a single page, brightly colored, and designed to be immediately recognizable and used by doctors and first responders alike.

The POLST form is signed by the patient’s doctor (or, in some states, nurse practitioner or physician’s assistant) and is a medical order. A copy is kept in the patient’s medical record, so it can be easily accessed in an emergency. Some states allow the forms to be logged into an electronic registry.

The POLST Paradigm, the national organization behind POLST, advises that POLST forms are not for everyone. They are recommended for “seriously ill or frail patients for whom their physicians would not be surprised if they died in the next year.”

Full Article and Source:
Planning with POLST


StandUp said...

It sounds like a great idea. Does it really work?

William Beckman said...

I am writing in response to your recent article "Planning with POLST." This article presents a favorable impression about use of the POLST form, but this form is dangerous and easily subject to aiding the abuses that your mission is working to prevent. This form can easily become a vehicle used by court appointed guardians to hasten the death of patients under their guardianship.

For example, with passage of SB 3076 this year in Illinois, the person discussing the POLST form with a patient does even not need to be a doctor. Patients can be manipulated by negative explanations of their options that encourage selection of limited care rather than full treatment. The form's terminology itself contributes to this problem by using phrases like "artificially assisted nutrition" rather than, for example, “Medically Administered Nutrition” .

Additionally, while there is a statement that indicates the POLST form should only be completed by people who are recognized to be approaching death (including such a statement near the end of your article), actual practice reveals that many more people are being asked to consider the POLST form that do not fit such criteria.

I have copied below additional concerns expressed about the Illinois POLST form during consideration of SB 3076 that has now unfortunately become law. Please also note that in some states no signature by the patient or his/her agent is required. In those states the medical staff representative who has a discussion about these issues records their own interpretation of the meaning of the responses and files that resulting medical order in the patient's file without any confirmation that the form actually reflects the patient's wishes.

I suggest that you take another look at the POLST form and its usage once established in a state. I recommend that you warn people to be very cautious about ever completing a POLST form.

Instead, patients should be encouraged to have a durable power of attorney for health care form, rather than a POLST form, so their designated agent can direct medical decisions according to their wishes rather than follow unforgiving medical orders that fail to consider the current circumstances.

Additional information expressing caution about the POLST form can be found at Pro-Life Healthcare Alliance (select "Issues" and then the first article listed), and (select "End of Life" and then "Euthanasia")


William Beckman
retired director of Illinois Right to Life Committee

William Beckman said...


1) Only the Physician should be able to sign a POLST form as it is in law now.
a. The amendment adding “practitioners” of physician’s assistants, advanced practice nurses and licensed resident after completion of one year in a program undermines the clear view that only physicians should discuss and work out the kind of medical care options with their patients. After that, the PA and nurse would help carry out the medical care options.
b. Note: Why require a resident physician to have completed at least one year in a program before signing a POLST, believing that is the minimum requirement of time to gain experience to counsel patients, while the physician’s assistant and advanced practice nurse are not required to have the same experience of at least one year like the physician?

William Beckman said...

2) The POLST form begins to replace the DNR advance directives under SB 3076, yet the POLST form is inadequate to clearly give options for the patient. There are no distinctions made for the patient between ordinary and extraordinary means. The actionable medical orders of the POLST are for terminal conditions as well as non-terminal conditions, without distinction. For example, if a person is diagnosed with a cancer that has a good prognosis of being eliminated with radiation and chemotherapy, lapses into no pulse and no breathing due to an allergic reaction to the chemotherapy, the POLST form that has checked “Do not attempt resuscitation” legally requires the patient not to be resuscitated even though any person would want to be resuscitated in that situation. This one size fits all is dangerous, especially for the elderly and frail people.
a) The POLST form should be revised, especially since it is becoming the premier DNR form, to give more options and explain terminal or dying situations opposed to non-terminal or non-dying situations or conditions.
b) The POLST form has a somewhat biased view of “do less for the patient.” Since POLST stands for “physician orders for life-sustaining treatment” there should be more options to sustain life. However, the current POLST form does not.
c) Wording changes would benefit patients and not be biased in trying to influence a patient’s decision. For example, under B Medical Interventions it starts with “Comfort Measures Only (Allow Natural Death) the least “life-sustaining”. Who isn’t for comfort measures and being allowed to have natural death? Sounds good. But it is not, it is biased against natural death since it doesn’t even include simple water and fluids by one of the least invasive medical helps which is the tiny IV tube.
d) Perhaps a check list of medical helps and aids would be good.
e) Box C “Artificially Administered Nutrition” might better be titled “Medically Administered Nutrition” Artificial sounds foreign, but it is only administering hyper alimentation or other by a tiny tube. Also, the check box “long-term artificial nutrition by tube can sound “under ending”. Perhaps, asking “medically administered nutrition only for as much time as needed”
f) The POLST form should have big and bright words stating “This form is voluntary and not mandated for you to sign” and “You can choose different options than are presented here for you – ask your physician”

William Beckman said...

3) Better Education of options for the patient should be a part of any POLST or advanced directive and better training of the physician on how to talk to their patients regarding POLST and their options.

4) Since physicians cannot sign and authorize a POLST form without the patient, or legal guardian or agent or other person designated by law, this should be clear in SB 3076. Also, it should be clear that POLST forms have a limited life themselves or expiration date if you will.

5) One good part of SB 3076 to mention and applaud is on page 2, lines 16-19 where it reverses an error in the law that currently states that “This advance directive does not replace a physician’s do-not-resuscitate (DNR) order.” It appears this means that a physician’s DNR of one year ago would supersede a POLST form signed today.