Select Data serves home health and hospice agencies throughout the country and the Virgin Islands. One agency, not from a POLST state recently asked that we write an article on POLST as they had seen the abbreviation on the Select Data SmartScribe forms. Their state is considering a move toward the Physician Orders for Life-Sustaining Treatment Paradigm program.
The POLST program is designed to improve the quality of care received by individuals at the end of life. It is designed to effectively communicate patient wishes through physician orders on a highly colored form (usually PINK) so as not to be missed by health care professionals.
What is the Difference Between POLST and Advance Directives?
POLST is a document that clearly states a patient’s end of life wishes and includes physician orders and patient signature. Advance Directives generally contain information about a person’s desire to be mechanically ventilated, artificially fed, and comfort measures. Advance Directives will not actively protect against unwanted emergency care, resuscitation specifics, or a transfer to an acute care setting. POLST includes CPR wishes, artificial nutrition choices, and specific statements identifying if a transfer to a hospital is desired. POLST has physician orders to back up the patient’s wishes.
History of the POLST Paradigm Initiative
Despite advance directives, medical ethics leaders recognized that patient wishes for life-sustaining treatments were not consistently being honored. In 1991, in Oregon, the POLST Paradigm Initiative was begun. The Medical Treatment Coversheet, designed to transport portable medical orders based upon the patient’s wishes emerged from the Initiative lead by The Center for Ethics in Health Care at Oregon Health and Science University. With stakeholders from several health care organizations, the Center coordinated the training of health care professionals regarding use of the form.
In 1995, the name of the Initiative was changed to Physician Orders for Life-Sustaining Treatment and the form was released for full use in Oregon. As the program satisfaction grew, other states sought legislation to initiate the program. West Virginia and New York were forerunners in program adoption and they lead the way in learning to integrate the new program within state specific laws.
Presently,(per www.obsu.edu/polst ), the Medical Treatment Coversheet is used by over 95% of nursing homes in Oregon and used by all hospices. It is considered “the accepted medical standard of care.” Together, with Oregon members, program leaders of New York, Pennsylvania, West Virginia, and Wisconsin joined together forming the original National POLST Paradigm Initiative Task Force. That Task Force has been instrumental in driving POLST Program development in California, Washington, Idaho, Colorado, Tennessee, and Virginia with several other states, such as Texas, Florida, Georgia, Indiana, Alaska, and Ohio actively developing programs.
The National POLST Paradigm Task Force (NPPTF): Program Requirements
The Task Force developed the description of the program with specific program requirements. The Program Structure requires an “effective statewide or regional coalition” working on a strategy to establish statewide implementation.
The Program requires a set of medical orders on the Medical Treatment Coversheet. There must be ongoing training of health care professionals at all levels, that includes an understanding of the POLST Program, its goals, use of the Form, as well as understanding “how to conduct a POLST conversation.” (www.obsu.edu/polst)
The Medical Treatment Coversheet includes physician signature. The patient signature is encouraged to be on the completed form as well which includes informed consent and shared medical decision making. The program requires a mechanism for ongoing evaluation and its processes. In addition, there must be a single “strong entity” within the state or region that accepts responsibility and ownership for the Program.
The Form and it’s Requirements
Treatment provided requires a specific medical order based upon the patient’s goals of care and their preferences. POLST offers three choices. First, Comfort Measures Only means care that would relieve pain and suffering. The medical orders “explicitly state in the medical orders that comfort measures are always provided.” (www.polst.com ) The patient is to be transferred if “comfort needs” cannot be provided. Second, the choice is “Limited Additional Interventions” that offer comfort measures as well as IV fluids and antibiotics. This option includes a choice to be transferred to an acute care setting only if suffering could not be relieved at home. The third choice is that of “Full Treatment” and includes the Comfort Measures, IV Fluids and antibiotic interventions as well as CPR and intensive care if needed. The orders must be signed and dated.
The Form must provide explicit direction as to resuscitation as well as patient preferences if they become pulseless or apneic. The Form must also include what the patient does NOT want including ICU, acute care, long term care, etc.
The Form must include the state of coverage. It is to be transportable so the patient may carry the Form within a state or region. The Form also clearly identifies a transfer option in case a patient’s comfort measures cannot be maintained in the present setting.