Max Diamond, M.D., Esen Sainz, J.D., MPH, Kendra Oliver, MBA
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Recommendation
The Physician Order for Life Saving Treatment (POLST) Form remains the standard method of advanced medical care planning for persons with advanced illness or frailty near the end of life. The POLST Form facilitates conversations about patients’ end-of-life wishes and allows health care providers to document those wishes more clearly in advance.
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 the “Code Status” of the preceding decades.
(This article is part in a series on the proper use of the POLST Form. View whole article and references.)
Physician Orders for Life-Sustaining Treatment (POLST) is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR. In 2020, a coversheet with the most commonly asked questions was added.
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