POLST: Honoring End-of-Life Wishes

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Max Diamond, M.D., Esen Sainz, J.D., MPH, Kendra Oliver, MBA

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Situation

1. California launched the Physician Order for Life Saving Treatment (POLST) Form on January 1, 2009. Today, the POLST Form remains the standard method of advanced medical care planning for persons with advanced illness or frailty near the end of life.
2. 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.
3. In an emergent situation, the design of the POLST Form provides a comprehensive overview  that lists first the patient’s decision on Cardiopulmonary Resuscitation (CPR). Over one decade of (in-field) experience, when completing the POLST form with patients, has taught physicians that the most natural conversation with patients and their families is to start at the bottom of the form (identifying the Legally Recognized Decision Maker), and then to work to the top of it (CPR).

Over its history, utilization of the POLST Form in California has given us a proven benchmark for the standard of health care.  The patient can express end-of-life wishes more clearly than ever before its implementation. Thanks to POLST, important end-of-life conversations have taken place routinely in offices, hospitals, and nursing homes. 

Background

In 2015, Governor Jerry Brown signed an executive order also allowing Nurse Practitioners and Physician Assistants to sign and validate the Physician Order for Life Saving Treatment (POLST) Form, which officially launched in California in 2009. POLST is a form that medical practitioners employ across all care settings for patients that are approaching the end of life.  Prior to the introduction of the POLST form in California, Hospitals and Nursing Homes needed to rely on individual physician’s orders which had great variability and, often, reflected only the patients’ wishes regarding CPR and intubation (Code Status).  For decades, institutions documented only Code Status in the medical record as either ‘Full Code’ or ‘DNR.’ 

Now, through the use of POLST, documentation of patients’ wishes includes other important end-of-life decisions such as the desire for artificial nutrition, palliative care, and comfort-focused treatment (e.g., no hospital transfer).  Office-based health care providers should initiate the POLST discussion with all of their patients who have a life expectancy of 5 years or less due to chronic illness or advanced age. In the absence of a POLST discussion in the office setting, the patient (or surrogate) is asked to document their wishes during the urgency of a hospitalization often by non-clinical hospital staff (such as an admissions clerk). Even when a clinical staff member provided a POLST discussion in the hospital setting, lack of interest, training, or the urgency of the medical condition rarely allows time for proper discussion and decision-making by the patient. This, of course, has resulted in what many professionals would consider catastrophic outcomes: The patient’s end-of-life wishes were not properly reflected, nor honored.

The California POLST Form has been written in 13 different languages, including Braille, making it linguistically accessible to essentially all California patients.  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 in a patient’s residence (e.g., refrigerator, bedroom, etc.) for both paramedic and family viewing.

Assessment

The purpose of the POLST Form is to facilitate communication between health care providers and their patients (or Legally Recognized Decision Maker) regarding their (personal) end-of-life wishes, and also to translate those wishes into clear medical orders.  The POLST Form is written in a format to expedite review during an emergency situation. As such, the form starts with CPR (Box A) and ends with identifying the Legally Recognized Decision Maker (Box D, illustrated here). 

Typically, when forms are organized in alphabetical sections like this, it is natural for the reader to begin with section “A.”  However, the layout of POLST was designed to follow the importance of decision-making during a crisis, not for the order of (ease in) conversation to complete the form.  Yet, many healthcare providers, by default, may review the POLST Form from A through D, which might make the initiation of meaningful conversations with the patient much more challenging. 

Recommendation

How to Start the Conversation: Health care providers should take note that a more natural (and less stressful) discussion of POLST is best accomplished by working up from Box D through A (starting at the bottom of the form and working to the top). This recommendation is based on the expert opinion of the (contributing physician) authors.

Health care providers should begin the conversation with Box D, stated as the following question: “Have you given thought to who can make decisions on your behalf in the case of a medical emergency?”  This is a much more organic way of leading into the questions asked in Boxes C through A.  In looking at the form above, you can see that the severity of the condition ascends from D (Information and Signatures) to A (CPR). Through (our) experience, it has become apparent that working your way up to whether the patient prefers a natural death (DNR) or CPR provides a much better experience for both the provider and the patient. (Note to healthcare providers: the Do Not Attempt Resuscitation/DNR decision in Box A is described as “Allow Natural Death.” This phrase proves very helpful to patients in understanding what this choice means and it is, therefore, our recommended approach to phrasing the question to the patient as well). Once the discussion begins, it tends to take a natural flow as you move up from D to A (reverse-)sequentially.

Note, advanced care planning is not a one-time event. As a patient’s health declines, their end-of-life wishes often will change. The POLST form should be revisited when a patient experiences a dramatic or sustained decline in health. The burden of repeated hospitalizations or advancing illness often prompts a patient to opt-out of life-prolonging interventions that they may have indicated as previously desired. Starting and maintaining documentation of your patient’s wishes is a vital component in the delivery of quality care.

The end of life only happens once. California’s health care providers have the all-important obligation to ensure that patients near the end of life have the opportunity to compassionately discuss and clearly convey their choices. Over the last decade plus, the POLST Form has paved the way for so many individuals to have all of their end-of-life wishes honored beyond just “Code Status” of the preceding decades.

The next article of this three-part series on POLST will discuss “The Hard Facts about Survival Rates.”

References

1.  California Code, Probate Code - PROB § 4780

2.  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/

3.  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/

4.  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

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

6.  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

7.  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.

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