Physician Orders for Life-Sustaining Treatment
POLST is an approach to improving end-of-life care in the United States, encouraging providers to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis. POLST began in Oregon in 1991 and currently exists at some level in 42 states and meets the national POLST standard in 18 states. The POLST document is a standardized, portable, brightly colored single page medical order that documents a conversation between a provider and a patient with a serious illness or frailty towards the end of life. A POLST form allows emergency medical services to provide treatment a patient wants before possibly transporting a patient to an emergency facility.
It is a medical order; the POLST form is always signed by a medical professional and, depending upon the state, the patient. A pragmatic rule for initiating a POLST can be if the clinician would not be surprised if the patient were to die within one year. One difference between a POLST form and an advance directive is that the POLST form is designed to be actionable throughout an entire community. It is immediately recognizable and can be used by doctors and first responders. Comparing to documents like DNI, DNR and advance directive, the POLST form provides more information on the types of end-of-life treatment or intervention patient wishes to receive.
Organizations that have passed formal resolutions in support of POLST include the American Bar Association and the Society for Post-Acute and Long-Term Care Medicine. Other organizations that support POLST include the American Nurses Association ; the Institute of Medicine; National Association of Social Workers ; AARP; the American Academy of Hospice and Palliative Medicine ; Pew Charitable Trusts; and the Catholic Health Association of the United States.
POLST orders are also known by other names in some states: Medical Orders for Life-Sustaining Treatment, Medical Orders on Scope of Treatment, Physician's Orders on Scope of Treatment or Transportable Physician Orders for Patient Preferences.
What is POLST?
POLST represents a significant paradigm change in advance care policy by standardizing provider communications through a plan of care in a portable way, rather than focusing solely on standardizing patients' communications via advance directives.The POLST paradigm requires providers and patients or their surrogates to
accomplish three core tasks:
- First, POLST begins with a conversation between a health care professional and the patient about treatment options in light of the patient's current condition.
- Second, the patient's preferences for treatments are incorporated into medical orders, which are recorded on a highly visible, standardized form that is kept at the front of the medical record or with the patient if the patient lives in the community.
- Third, providers encourage that the POLST form travels with the individual whenever he or she moves from one setting to another, thereby promoting the continuity of care throughout a community.
In a 2006 consensus report, the National Quality Form observed that "compared with other advance directive programs, POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals." The National Quality Forum and other experts have recommended nationwide implementation of the POLST paradigm Implementation of POLST was also recently recommended by the National Academy of Sciences Institute of Medicine in its report, "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life." The report was released September 17, 2014.
What is on the POLST Form?
The POLST form is usually on brightly colored paper that contains options for the patient depending on the patient's health status. The POLST form generally has sections for the patient to decide whether or not they would want cardiopulmonary resuscitation, the preferred level of medical interventions, or whether the patient would want artificially administered nutrition. Depending on the state, there could be another section on whether to provide antibiotics or not to the patient.Cardiopulmonary resuscitation (CPR)
The first section in most forms across the country is Section A indicating the option between performing cardiopulmonary resuscitation or no CPR or do not attempt to resuscitate. The national form indicates mechanical ventilators, defibrillation and cardioversion under the CPR specifications. A study showed that there was a high rate of providers respecting the patients' decisions regarding CPR, which means that the providers respected the patients' wishes according to the POLST forms.Preferred Medical Interventions
The level of medical intervention is on section B on the POLST form with options of "comfort measures", "limited additional treatment", or "full treatment". This section only comes into play if the patient still has a pulse and/or if the patient is still breathing. The "comfort measures" allow for natural death and only helps the patient relieve any pain. By checking this box, the patient also prefers to not be transferred within the hospital. The "limited additional treatment" includes the comfort measures in addition to basic medical treatment. “Full treatment” authorizes the medical team to try their best to save the patients and increases their life expectancy with all methods. This option also allows patients to choose whether they would like a trial period. A study on nursing home residents has shown the high rate that the medical teams respected the patients’ wishes and gave the treatments according to the orders on section B.Artificially Administered Nutrition
This section comes with options of “no artificial nutrition by tube”, “defined trial period of artificial nutrition by tube” and “long-term artificial nutrition by tube”. If patients are able to chew and swallow, the food will be taken by mouth. Studies have found that orders to withhold artificial nutrition such as feeding tubes are usually executed by the providers.Antibiotics
For most versions of POLST, orders on antibiotics have three aspects: antibiotic use to enhance comfort, the use of IV/IM antibiotics, and the use of antibiotics at time of disease or infection. Studies have found orders on the use of antibiotics for comfort measures tend to have high rates of execution. However, one study has shown that providers do not always obey the patients' wish to not use antibiotics. Because certain types of infection have other means to alleviate symptoms of infections, so physicians' use of antibiotics seem to be generally unaffected by POLST.How is the Form Used?
Before executing the orders on the POLST form, the provider should talk with patients with decision-making capacity to obtain the most updated wishes from their patients. This process or conversation could involve families and relevant care providers as well to ensure the patient is well-informed while making the decisions. If the patient has made changes to the POLST form, the provider is responsible for explaining how the updates will likely impact future treatment plans. However, if the patient is not able to make decisions because of his or her disease state, the clinicians have to follow orders on preexisting POLST forms.Differences between an advance directive and a POLST Form
Advance Directive
An advance directive is a legal document that allows you to share your wishes with your health care team if you can’t speak for yourself. It does so by designating a person you want your medical team to work with. Competent patients above 18 years of age can fill out an advance directive. An advance directive allows you to generally state what treatments you would or would not want in a medical crisis, but it is not a medical order. Advance directives are not portable in a sense that it is not accessible across medical systems, so it is the patients' responsibility to have the form on them at all times. This can bring up challenges as it can be difficult to locate and may need to be interpreted when it is needed.POLST Form
Unlike advance directives, a POLST summarizes the patients' wishes in the form of medical orders, but should only be used when the patient is at the end of life. You cannot identify a surrogate using a POLST Form. To designate a health care surrogate, patients must use an advance directive. POLST provides explicit guidance to health professionals under predictable future circumstances based on your current medical condition. A POLST form turns treatment wishes outlined in an advance directive into medical orders. The POLST form is reviewed more frequently compared to an advance directive to make sure that the form complies with the patient's wishes in treatments as the disease progresses. An individual does not need to have an advance directive to have a POLST form although health care professionals recommend that all competent adults have advance directives in place. If the individual lacks decisional capacity, a surrogate can engage in the conversation and the consent process that forms the basis of the POLST process.The POLST form is very portable unlike the advance directive. It is the physicians' responsibility to make it accessible across different medical facilities.
The challenges that patients, their families and their healthcare professionals face in a medical emergency can be daunting. Caring and sensitive communication can elicit patients' wishes that can then be documented in an advance directive. To put these preferences into actionable orders requires an additional tool, the POLST form. Healthcare professionals and their organizations can overcome the myriad barriers to communication across systems of care by developing a POLST program, creating a method that respects some of the most deeply held values of patients.