End of Life Care Manual

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Section 6: The Physician Orders for Life Sustaining Treatment Program: A Simple Approach to Communicating Your Patient's Medical Care Decisions

 

The goal of the Physician Orders for Life Sustaining Treatment (POLST) program is to effectively communicate the wishes of seriously ill patients to have or to limit life-sustaining medical treatment as they move from one care setting to another(1). There is a tremendous amount of emotion involved when it comes time to determine what type of care an individual wants ordered by his or her physician in preparation for possible life-threatening medical events. The Physician Orders for Life Sustaining Treatment (POLST) form is a tool that facilitates this decision process. The POLST form also ensures that a patient's end-of-life care decisions are made known to health care providers, family members, and emergency personnel. It is also helpful for initiating compassionate end-of-life discussions with patients and family members.

The materials following this overview of POLST are intended to assist facilities in implementing the POLST program and encouraging its use among staff and patients. Included in this section are:



The key aspects of the POLST form are:

  • A POLST form may be appropriate for anyone with a serious and/or life-limiting disease.
  • The POLST form is portable, following the patient through all care settings, including home, emergency rooms, hospitals, and nursing homes.
  • When completed, the POLST form is a physician order, treated as such.
  • The POLST form is not an advance directive. It may complement an advance directive, but is a separate document.
  • The form must contain signatures from both the patient and provider.

The POLST program originated in Oregon and has been used in Washington since 2000. The program developed from collaboration by providers and interested parties and the promotion of the use of POLST has been a grassroots effort. In Washington State, the POLST form has replaced EMS-No CPR forms.

POLST is widely used and accepted for a number of reasons. The form promotes patient autonomy, clarifies treatment wishes, and facilitates appropriate treatment. Additionally, the form translates patient decisions into actual physician orders that are recognizable at an emergency site, emergency room, hospital, or long-term care facility such as a nursing home or hospice. The POLST form ensures that first responders can immediately ascertain a patient's wishes regarding medical treatment. The form travels with the individual through every care setting, gives standardized information, and reduces the need for repetitive end-of-life discussions. Importantly, POLST also offers both patient and physician comfort and security in knowing that the options and choices they discuss will be carried out no matter what the care setting.

POLST is appropriate for any adult patient over the age of 18 with a life-limiting medical condition, especially anyone who has chosen "Do Not Resuscitate" or "No Code Status" in response to a full cardiorespiratory arrest. The standard question a physician should ask of himself or herself when deciding to initiate a POLST form is: would it surprise me if this patient died in six months to a year? Physicians who foresee the possibility that a patient may not live through the year should recommend a POLST form be completed. This could be applicable to a patient with a serious medical condition, as well as an elderly patient.

The POLST form is not an advance directive and does not replace or mitigate the importance of advance directives. Though it may complement a living will or durable power of attorney for health care, it is a separate and distinct tool in end-of-life care. Living wills are limited in the amount of information they can provide. A durable power of attorney serves mainly to appoint a surrogate decision-maker for health care decisions in the event that the patient cannot give consent. A POLST form offers a more detailed record of decisions made while the individual or surrogate decision-maker has the very latest information about health concerns and options. The POLST form translates the black and white wishes expressed in advance directives into physician orders that better encompass the nuances of a specific situation.

POLST is a straightforward two-sided form(2). The front of the POLST form allows the person completing the form to "check the box" indicating types of care desired by the patient. Choices on the front of the form include: resuscitation, medical interventions, antibiotics, and artificially administered nutrition. There is also a section to summarize the goals of the treatment plan. While comfort care is always emphasized, the patient may choose aggressive or non-aggressive treatment options. The back of the form gives contact information, additional directions on the use of POLST, and a section for review of the POLST form. The form should be reviewed periodically and upon transfer, change in health status, or change in the patient's treatment preferences. If the POLST form is changed, void the old form and fill out a new one. A POLST form may be revoked at any time by a patient with capacity or by the surrogate decision-maker if the patient lacks capacity.

The POLST form may be presented to the patient and discussed by a member of the health care team ? including a nurse, social worker, or chaplain ? but must be reviewed with the patient and signed by a physician, nurse practitioner, or physician assistant. The form should be completed after discussion with the patient or legal surrogate decision-maker regarding the individual's preferences. The form is not operational unless signed by both the health care provider (physician, nurse practitioner, or physician assistant) and patient or surrogate. Both signatures must be present for the patient to receive the end-of-life care indicated on the POLST form. Signatures may be faxed and attached to the form as an addendum or the entire form may be faxed back and forth in order to get a provider signature.

The ideal time to fill out a POLST is in a non-emergency setting. Discussion during a routine office visit allows the physician, patient, and family time to consider and discuss treatment options and implications. POLST forms may also be completed during inpatient treatment, prior to discharge, or upon admission to a hospice or long-term nursing facility.

The POLST form is two-sided and printed on bright green paper. The form may be photocopied and the paper color is not mandatory, but the bright green paper is encouraged as it promotes visibility and recognition in each care setting and facilitates its use and transfer with the individual. Emergency personnel are more likely to recognize the form in a home care setting if it is this standard color. The POLST form in this section is a standard example of the current form. Printing on cardstock makes the form more durable and visible, but may hamper faxing.

If the holder of a POLST form is in a health care facility, the form should be at the front of the clinical record ? obvious and easily recognizable. The original form travels with the patient when transferred or discharged, but a copy may be kept in the patient's record, depending on the policy of the institution. If the individual chooses to remain at or return home, ensure that the original POLST form is taken home with the person and suggest that it be posted in a highly visible place. Standard locations include the refrigerator door, the back of the bedroom door, the front of the medicine cabinet, or beside the individual's bed. Emergency personnel will look to these common, prominent locations upon entering.

The POLST form is used extensively in Washington State and is endorsed by several associations and state agencies. The form is endorsed by the Washington State Hospital Association, the Washington State Medical Association, and the Association of Washington Public Hospital Districts. The Washington State Department of Health (DOH) supports the POLST form and the Department of Social and Health Services (DSHS) allows the use of the POLST form in nursing homes.

RCW 43.70.480 directs the Department of Health (DOH) to adopt guidelines and protocols to train emergency medical personnel in responding to the site of an emergency to treat a patient who has indicated, in some written form, that he or she does not wish to receive futile emergency medical treatment. The statute further directs that these protocols be set forth in a "simple form" to be used statewide. DOH has adopted POLST to fulfill this statutory requirement. The department trains members of the Emergency Medical Services and Trauma System in how to use a POLST form should one be present at the scene of a medical emergency. DOH will authorize the use of the POLST form in any Washington State county.

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  1. http://www.ohsu.edu/polst Accessed July 19, 2007.
  2. The POLST form is periodically reviewed and revised. Older versions are valid, but providers are encouraged to use the latest version.