By Eileen Beal
The problem: You’d think that advance directives (guide and form from the American Bar Association) signed by people with serious, life-threatening illnesses (often when they’re admitted to a hospital or nursing home) would ensure their treatment preferences or end-of-life wishes would be carried out. Too often this isn’t the case because:
- patients (or their surrogates) create these documents
- they are overlooked/ignored/forgotten in crisis situations (i.e. emergency medical service calls, emergency department visits)
- they usually don’t make it into the patient’s medical records (with the exception of Do Not Resuscitate orders)
One solution: Physician Orders for Life-Sustaining Treatment – POLSTs – are summaries of a patient’s advance directives related to their current medical situation. They are created after a thorough discussion with a medical practitioner (most often a physician, nurse practitioner, or social worker; often caregivers are also involved in these discussions) and cover:
- what the patient wants done if EMS is called
- which medical treatments patients want in a hospital or a nursing home. Options include limited medical treatment, full treatment, comfort care, and much more
- preferences with regard to antibiotics, tube feedings, where they want to die, etc.
When signed by the patient’s physician (and increasingly, the patient), these summaries become physician’s orders – actionable medical document that outline the procedures, treatments and care patients with serious life-threatening or life-limiting conditions should receive. In effect, POLSTs are end-of-life documents, thought they are seldom referred to as such. (Note: Depending on the state, POLSTs are also called Provider Orders for Life Sustaining Treatment and MOLSTs, Medical Orders for Life-Sustaining Treatment.)
How POLSTs work: POLSTs are medically and legally recognized documents that are placed up front in the patient’s written and electronic medical records. Research (see articles cited below) indicates they improve interactions between patients, families and medical providers as well as the quality of care people receive because they:
- turn a patient’s wishes into medical orders
- are printed on brightly colored sheets that are impossible to miss
- include a promise by current health care professionals – including,where possible, EMS personnel – to honor those wishes across all health care settings
- go with the patient when they are discharged or transferred to another health care setting or home
Do POLSTs replace Advance Directives?
Advance directives are recommended for everyone; POLSTs are primarily for those with serious life-threatening illnesses or advanced life-limiting conditions. However, they reinforce and complement each other and there is growing acknowledgement of their usefulness in both the health care and legal fields.
Where are POLSTs used: Currently, these documents are being used in 14 states and being considered in 22 more. Each state’s POLST initiative has been collaboratively designed by local stakeholders – representatives from hospitals/hospital systems, hospices and community EMS programs; consumer groups; university-based law-medicine, ethics and aging centers; insurance companies; state and local health and mental health boards; etc. Most states have one or more contact persons.
Concerns and controversies: Even those who support POLSTs are concerned with the form’s language: many complain about its “poor wording,” and say that it’s loaded with “negative connotations. The forms need to be fine-tuned and become more patient-friendly, many experts say. Another concern is that physicians may not have sufficient time to explain or clarify the highly individualized risks and benefits of various types of end-of-life care to patients, especially those who are cognitively impaired. For its part, the National Catholic Bioethics Center, “favors the designation of a health care agent” (a person) over any type of advance directive, including POLSTs.
History/Background: The POLST initiative began in 1991 through the efforts of The Center for Ethics in Health Care at Oregon Health & Science University, and by 1995 members of a POLST task force had educated healthcare professionals throughout Oregon about use of the form. West Virginia, New York, Pennsylvania, Washington, and regions of Wisconsin quickly adopted programs similar to Oregon’s – after “retooling” the initiative to meet state laws and regulations.
Story Ideas:
- Compare and contrast standard advance directives (used in and available for every state) and POLSTs directives (currently available in 14 states).
- If your state is working toward adopting POLST documents, cover the process: who is championing the initiative; where it is in the political process; what organizations and/or groups support and oppose it; how does it fit in with regard to end-of-life values and practices in your state..
- Profile a patient/family that has gone through the process of creating a POLST and what happened when medical decisions had to be made..
- Profile a POLST team (usually some combination of physician, nurse/nurse practitioner, and social worker): where they practice; what each person on the team does (brings to the process); the physical process of inserting/adding a POLST document to a patient’s medical records; etc.
Resources
Experts on POLSTs (and related issues) (Note: contact info is current as of 12-05-11.)
- Margaret Murphy Carley, JD, RN, Executive Director, POLST Paradigm Task Force (Oregon)
Phone: 503-494-3965 Email: carley@ohsu.edu - Patricia Bomba, MD, FACP, VP and Medical Director, Geriatrics, Excellus BlueCross BlueShield (New York)
Phone: 585-238-4514 Email: patricia.bomba@lifethc.com - Alvin Moss, MD, Professor of Medicine and Director, Center for Health Ethics and Law, West Virginia University (West Virginia)
Phone: 304-239-7618 Email: amoss@hsc.wvc.edu - Judy Citko, JD, Ex. Dir, Coalition for Compassionate Care of California (California)
Phone: 916-993-7740 Email: jcitko@CoalitionCCC.org - Charles Sabatino, JD, Director of the American Bar Association’s Commission on Law and Aging (Washington, DC)
Phone: 202-662-8686 Email: charles.sabatino@americanbar.org - Judith Black, MD, MHA, Medical Dir, Highmark (an association of BlueCross BlueShield plans) (Pennsylvania)
Phone: 412-544-3523 Email: judith.black@highmark.com - Maureen Henry, JD, Ex. Dir, Utah Commission on Aging (Utah)
Phone: 801-585-6835 Email: maureen.henry@utah.edu - Terri Schmidt, MD, Emergency Services, Oregon Health & Science University (Oregon)
Phone: 503-494-3965 Email: carley@ohsu.edu - Naomi Karp, JD, Senior Strategic Policy Advisor, AARP’s Public Policy Institute (New York)
Phone: 202-434-3924 Email: nkarp@aarp.org. - Margaret Ann Metzger, JD, former Executive Director, Massachusetts Commission on End of Life Care (Massachusetts)
Phone: 781-239-1153 Email: pegmetzger@verizon.net
Websites:
- American Bar Association Commission on Aging
- Giving Someone a Power of Attorney For Your Health Care
- Glossary: Terms related to Advance Directives and End of Life Care
- POLST Paradigm Initiative
- Wall Street Journal (podcast by Laura Landro)
Articles
- “Decisions about End of Life Care,” JAMA
- “End-of-life care: an Oregon innovation helps people avoid unwanted interventions,” Joe Rojas-Burke, The Oregonian
- “Enough: The failure of the living will,” Hastings Center Report, 2004 (report)
- “Systemic Review: the effect on surrogates of making treatment decisions for others,” Weldner, D, Rid A., Ann Intern Med (abstract)
- “The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form,” Hickman, S.E, PhD., et. al , J American Geriatrics Society
- “The Evolution of Advance Directives,” D. B. White, MD and R. M. Arnold, MD, JAMA,
- “The POLST Paradigm Improves End of Life Care,” Getz, L, Aging Well Magazine
- “The POLST Paradigm: Respecting the Wishes of Patients and Families,” Dunn, P.M, MD, et. al, Ann of Long Term Care
- “They are going to unplug grandma: Advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death,” Fischer, S. M., MD, J Hospital Medicine
- “Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting,” Hickman, S.E, PhD, et. al, J Palliative Medicine
