POLST 3: Honoring End-of-Life Wishes
What is the origin of the POLST form?
Max Diamond, M.D., Esen Sainz, J.D., MPH, Kendra Oliver, MBA
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History
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. Today, the POLST form remains the standard for end-of-life medical conversations.
(This article is part in a series on the proper use of the POLST Form. View whole article and references.)