Eliciting Patients’ Wishes in Emergent Situations.
Max Diamond, M.D., Mary-Kate Kelledy, J.D., Kendra Oliver, MBA
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Situation
- California launched the Physician Order for Life Saving Treatment (POLST) Form on January 1, 2009. Today, the POLST Form remains established as the standard method of advanced medical care planning for persons with advanced illness or frailty near the end of life.
- The POLST Form has facilitated conversations about patients’ end-of-life wishes and allowed health care providers to document those wishes more clearly in advance.
- The questions on the POLST form empower patients with the ability to declare the scope of treatment they wish to receive during end-of-life care. Given the value of the aftereffect of these questions, they must be asked in a manner which is not only clear and empathetic, but also one that ultimately reminds the patients 1) that they are encouraged to discuss their concerns, and 2) that their wishes will ultimately be met.
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.
Background
The Physician Order for Life Saving Treatment (POLST) Form documents patients’ decisions regarding the following areas: attempted cardiopulmonary resuscitation, administration of antibiotics and IV fluids, the use of intubation and mechanical ventilation, and the use of artificial nutrition. Each of these categories consists of relatively short prompts which, then, lay a foundation for medical professionals 1) to provide the care patients actually want, and 2) to abstain from treatment they do not want. In other words, the patients’ wishes are sought out, recorded down, and administered precisely, either to accept or to avoid certain treatments.
The form can be completed and signed by any provider who is in a treatment relationship with the patient. Treating providers include the primary care physician, consulting physicians, hospitalists, nursing home physicians, and emergency department physicians. There is no hierarchy that necessitates which type of provider should administer the form. The provider must, however, have knowledge of the patient’s medical condition, prognosis, and capacity to make decisions. The treating provider must, primarily, have a willingness to collaborate in discussion with the patient about their preferred choices.
The precondition of a willingness to collaborate is arguably the most important of the requirements because it embodies the very spirit behind the creation of the POLST form. A physician’s knowledge of the patient’s condition is obviously important, but their discussion with the patient is the mechanism that ultimately elicits the patient’s wishes. To that same end, while the patient must communicate their end-of-life wishes, the provider (on the receiving end) must determine to be both present enough to understand exactly what the patient is saying and astute enough to clarify any suspected confusion. Each of these requirements necessitates patience, ample time, and a commitment to pursue the patient’s wishes.
Therefore, it is not enough that a POLST discussion be simply provided by any admitting clinical staff member in a hospital setting. Not at all. Hospitals (and other medical providers) must continue their proactive efforts to guarantee that the staff member administering the form is also properly trained in compassionately eliciting a patient’s wishes. Further training is likely required to address instances where the urgency of a medical condition does not allow time for a full, proper discussion and decision-making by the patients. That is, the truly skilled clinician knows how to elicit the patient’s wishes (often through family members) rapidly, yet compassionately, in an emergent situation.
Above all, the medical community must continue to recognize the delicacy of the conversation between the provider and the patient. When administering the POLST form, both parties will likely recognize the reality which has brought them to this point of conversation. The physician, with all their training, faces a patient whom they know is in a life-threatening state. The patient, helpless and ill…cannot but feel the pungency of the declining state they face. Given the high emotional gravity of the situation (as well as the amount of time it takes to properly administer the form), it is crucial that medical providers seek training to understand what the questions on the POLST form mean and how to ask them appropriately. In doing so, clinicians will ease their personal anxiety about having these difficult conversations.
The POLST Form is available online for bulk orders or for free download at www.capolst.org. POLST California recommends the form be printed on bright neon pink cardstock paper to ensure it stands out in a thick medical record or when posted on a patient’s refrigerator (for both paramedic and family viewing).
Another article of this series on POLST will explore “Unbiased Solicitation of Patient Needs and Wishes.”
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.
