Compassionate Utilization of the Form

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Max Diamond, M.D., Mary-Kate Kelledy, J.D., Kendra Oliver, MBA

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Acclimation

The POLST form is not just a form; it is a tool for medical providers to administer individualized, compassionate care. At a time when patients likely feel helpless in many respects, the POLST form entrusts them with the freedom to discuss and define their own quality of life, individually. The significance behind this decision-making process gives reason to elaborate this topic. This article is part of a series on the use of the POLS T Form with patients.

Recommendations

The Importance of the Questions: Health care providers should take note that the only way to understand a patient’s wishes for their end-of-life care is to take the time to compassionately explain what the questions on the form actually mean in practicality. The providers must also be committed to securing the patient’s wishes even when they personally or professionally may disagree with the decision, and must be comfortable explaining the truth of the statistics behind the medical treatment to the patient’s loved-ones. This recommendation is based on the expert opinion of the authors. 

Health care providers should adapt the conversation concerning Box A stated as the following question: “Do you understand what the word ‘resuscitation’ means?” This is a much more organic way of leading into the choices asked for next, which seeks the patient’s decision on whether or not they want to be resuscitated. Of course, preliminary questions of this nature demand more time from the provider administering the form, but they serve the vital importance of obtaining an educated and informed response from the patient. The medical provider should also take the time to consider whether the patient is engaged in the conversation and if their responses are genuine, as opposed to dismissive answers which could be the result of current confusion or pain. 

As discussed previously, if the patient chooses to “Allow Natural Death (DNR)” the provider must honor the decision, even if they would be personally or professionally inclined to attempt resuscitation. The goal is to focus on the fact that POLST exists to serve the end-of-life wishes of the patient and that their desires must honored and respected. 

Sometimes, it may be the case that honoring and respecting the patient’s choices requires an in-depth discovery into any other requests that they may have. Box C, addressing “Artificially Administered Nutrition” exemplifies this scenario. Box C specifically includes a section that allows for “Additional Orders” by the patient. An inappropriate and rushed discussion with the patient would likely include the following type of question, “Do you have any additional orders?” However, the problem with this question is that it does not set the parameters of what additional orders are available to the patient. More clarity needs to be provided. Is the patient being asked about the type of nutrition in the tubes? Dietary restrictions? Time restrictions? It is difficult to tell. A more compassionate question, one which truly seeks to understand the patient’s desires for their own end of life treatment, might be asked this way instead: “Do you have any other specific requests when it comes to your nutrition…? For example, is there a time-frame when you would want to discontinue the nutrition…? Do you have any nutritional needs or restrictions we are not aware of...?” Here, the physician still guides the conversation by applying their own expertise but broadens the scope of the questions with more detail to define the patient’s end-of-life needs more succinctly.  

Another article of this series on POLST will explore “The Patient Experience.”

References

1.  POLST Education. Retrieved October 2018 from https://familydocs.org/eol/education/polst

2.  California POLST Form. Retrieved September 2018, from https://capolst.org/wp-content/uploads/2017/09/POLST_2017_Final.pdf

3.  The Physician Orders For Life-Sustaining Treatment (POLST) Coming Soon To A Health Care Community Near You, Robert B. Wolf,  Marilyn J. Maag, and Keith Bradoc Gallant, Retrieved October 2018 from http://www.polst.org/wpcontent/uploads/2014/11/WolfMaagGallantVol49No1.pdf

4.  The Coalition for Compassionate Care of California.  POLST for Healthcare Providers. – Legislation & Public Policy.  Retrieved September 2018, from https://capolst.org/polst-for-healthcare-providers/

5.  California Health Care Foundation.  (2009, January).  CHCF Directs $2 Million to Spur Adoption of New End-of-Life Communication Tool - Recently approved POLST form gives seriously ill patients greater ability to control medical treatment.  Retrieved September 2018, from https://www.chcf.org/press-release/chcf-directs-2-million-to-spur-adoption-of-new-end-of-life-communication-tool/

6.  Dunn, P.M., Tolle, S.W., Moss,A.H., and Black, J.S. (2007, September). The POLST Paradigm: Respecting the Wishes of Patients and Families.  Annals of Long-Term Care, 15 (9), 33-40.  Retrieved September 2018, from http://www.polst.org/wp-content/uploads/2013/01/the+polst+paradigm+respecting+wishes.pdf

7.  Pope, T.M., Hexum, H.  (2012). Legal Briefing: POLST: Physician Orders for Life-Sustaining Treatment. The Journal of Clinical Ethics, 23(4), 353-76.  Retrieved September 2018, from https://pdfs.semanticscholar.org/a142/bc9501f50610297654e085eeb9752da72e34.pdf

8.  IOM (Institute of Medicine). 2015. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press.

9.  Cantor, M.D., et al. (2002, August). To Force Feed the Patients With Dementia or Not to Feed: Preferences, Evidence Base, and Regulation. Annals of Long Term Care, Volume 10, Issue 8.

For additional information please contact Dr. Max Diamond at 714-221-5182 or mdiamond@regalmed.com.