Physician Orders for Life Sustaining Treatment (POLST)

Presenters:

Sally Denton, BSN, RNCPresident/AdministratorSt. Joseph Care Center

What is POLST?

“Portable” physician orders for end-of-life care

Replaces EMS-No CPR form Travels with patient Can translate an Advance Directive

into physician’s orders REMEMBER: Conversations for

goals of care come first! REMEMBER: Power and Portability

Philosophy of POLST

Individuals have the right to make their own health care decisions

These rights include:– Making decisions about accepting

or refusing life sustaining treatment– Having their decisions honored by

health care providers– Comfort care while having wishes

honored

Initiating POLST in Washington Community Forum and RENEW

(Regional Ethics Network of Eastern Washington) January, 2000

DSHS Task Force and surrogate decision making issues

WSMA PACE grant

POLST Pilot Program

Washington State Department of Health and EMS training

Training for 24 SNFs with DSHS support

Hospitals: Policies and Procedures Physician education and recruitment

POLST Pilot Program, cont.

Pilot started August 2000

6 SNF, 21 patients

Evidence of informed consent

Congruence of stated wishes with completed POLST

POLST Pilot Program, cont. Washington DOH accepts POLST

for statewide use and commits to EMS training

WSMA commits to physician and consumer POLST education

WSHA and AWPHD adds POLST to End-of-Life Hospital Resources and actively promotes POLST education and implementation

DSHS notifies residential care facilities of use of POLST

How POLST Works

POLST vs. EMS Form

Both forms:– Are physician orders recognized by

Washington DOH and EMS (911)– Allow “Do Not Resuscitate” choice if

no pulse or respirations Only POLST includes orders for

medical interventions when person has pulse and/or is breathing

POLST: Who Should Have One? Anyone choosing:

– Do not resuscitate– No code– Allow natural death

Anyone choosing to limit medical interventions

Anyone “you anticipate might die within the next year”

POLST Form Part A

Resuscitation: Includes EMS Patient has no pulse and is not

breathing – Resuscitate – Do Not Resuscitate (allow natural

death) – Comfort measures will always be

provided

POLST Form Part B

Medical Interventions: Person has pulse and is breathing.

Comfort Measures Only: Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction as needed for comfort.

Limited additional interventions: Includes care described above. Use medical treatment, IV fluids and cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation.

Full Treatment: Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated.

Additional Orders: (e.g. dialysis, etc.) __________________

POLST Form Part C

No Antibiotics. Use other measures to relieve symptoms.

Determine use or limitation of antibiotics when infections occurs, with comfort as goal.

Use antibiotics if life can be prolonged.

POLST Form Part D

No Artificially Nutrition by tube Trial period of artificial nutrition

by tube. (Goal:__________) Long-term artificial nutrition by

tube Additional orders:____________________________

POLST Form Part E

Discussed with: – Patient/Resident– Agent of DPOAH– Court-appointed guardian– Spouse– Other (Specify)– Parent of minor

POLST Form Part E, continued

The basis for these orders is:– Patient’s request

– Patient’s known preference

– Patient’s best interest

– Medical futility

POLST: Signatures

Documents informed consent process

Requires physician signature Requires patient/resident or legal

surrogate signature Signatures are the most common

logistical problem!

POLST: Who Fills It Out?

Physician or physician designee

Signatures attest to the informed consent process having occurred

Different facilities designate/train different personnel for this purpose

Transfer

Original bright lime green form– Transferred with individual to be

valid (Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid.)

Health care institutions– Keep duplicate copy in permanent

medical record upon discharge– Also make copy prior to inter-facility

transports

Revocation of forms

Patient– Verbally revoking order– Destroying form and/or No CPR

bracelet Physician or legal surrogate

expresses patient’s revocation Line out “physician orders” Write “VOID” then initial

POLST in Hospitals

POLST forms may be initiated in hospitals

Sample policies and procedures are available

Form must be visible in chart Staff must be trained and updated

on interaction with other end-of-life documents

POLST in Skilled Nursing Facilities Policy describing POLST use required New resident

– SNF can honor POLST for up to two weeks

– Review during first comprehensive assessment period

On review– Document that form contains current

wishes OR– Complete new form

Physicians and POLST

Washington State Medical Association

Form appropriate for:– Patient you would not be surprised

if they died within the next year– Any patient choosing to limit

medical interventions (encourage family conversations)

Local educational efforts

POLST in the Community

Integrating POLST in the Community EMS service providers trained Hospitals update policies to

address POLST Nursing homes also update

policies--surrogate decision making issue may arise

Physicians trained

Integrating POLST in the Community-Continued Training for hospital and nursing

home staff Other entities and persons

– assisted living– adult day health – estate planning attorneys

Other awareness activities for the community

Helpful Hints on Integrating POLST in the Community

Establish a “Go Date” Hospitals and nursing homes can

meet to draft consistent policies Hold a community-wide

preparedness meeting

POLST Resources

POLST Resources: Required Training Emergency Medicine and

Trauma Prevention, Department of Health– Phone (360) 705-6700– www.doh.wa.gov/hsqa/emtp/

Provides required EMS service provider training

POLST Resources: Forms

Graham Short, Washington State Medical Association– Phone (206) 956-3649– E-mail gfs@wsma.org

POLST Resources: Information, Policies, and Procedures

Association of Washington Public Hospital Districts web site– www.awphd.org/resources_endoflife.asp

Washington State Department of Health– http://www.doh.wa.gov/hsqa/emtp/

resuscitation.htm

Questions