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The POLST Paradigm: Improving End-of-Life Care
By Lindsey Getz

Physician Orders for Life-Sustaining Treatment (POLST) forms turn individuals’ treatment wishes into actionable medical orders that can be taken from one care setting to another.

When critical life-sustaining decisions must be made, there are often many gray areas. When should (and shouldn’t) antibiotics be administered? Should a patient be admitted to the ICU? Is it the patient’s wish to have a feeding tube? In the past, an advance directive has been the primary document created with the intention of answering questions about end-of-life care.

However, advance directives aren’t always specific enough and sometimes aren’t easily accessible in moments of urgency. What’s emerged as a complementary option is a Physician Orders for Life-Sustaining Treatment (POLST) form. While this medical order form is available in more than one half of the 50 states, many patients and their caregivers are still not educated on what they are and how to complete one.

The form accomplishes two major purposes: turning an individual’s treatment wishes into actionable medical orders and doing so in a format that is portable from one care setting to another. Not all states offer a POLST-type program (often referred to as a POLST Paradigm, as different states have different names for such programs. For instance, New York’s is called MOLST for Medical Orders for Life-Sustaining Treatment.), but the movement has been gaining ground. Currently, more than 30 states offer a POLST paradigm program, and that number continues to grow. (A frequently updated map of which states offer such a program is available at www.polst.org.)

It’s important for elders and their caregivers to understand that a POLST form is not meant to replace an advance directive but rather to complement it. An advance directive appoints a legal healthcare representative and provides instruction for future life-sustaining treatment, explains Susan Tolle, MD, director of Oregon Health & Science University’s Center for Ethics in Health Care. “Anyone 18 or older could complete an advance directive,” she says. “It’s very future oriented—talking about what you’d want should something bad happen or should you reach an end-of-life stage.”

While an advance directive is valuable, one problem is that it often becomes outdated as the years pass. Tolle says a patient’s wishes can be quite different from when he or she was healthy vs. sick or dying. When an advance directive was created, that healthy and thriving person may have wanted a lot of intervention should his or her life be threatened. Once sick—and perhaps in pain—those wishes can change drastically. “Basically a POLST form turns an advance directive into action in a time of need,” says Tolle. “You’re no longer talking about the future; you’re talking about now. You already know the health problems you have. So now the question is what specific treatment do you really want?”

It’s also important to note that a POLST form, though more likely to be used by elders, is not dependent on age. The form is for any person with an advanced chronic illness or frailty who is near the end of life. A 65-year-old in great health would not be a candidate for a POLST form; a 50-year-old in the advanced stages of a life-threatening illness would be. “An individual being moved into a nursing home—not just for rehab but as a permanent home—would be a POLST candidate,” explains Tolle, “as would a patient that’s been enrolled in hospice.”

Another issue with end-of-life wishes that POLST may resolve is that an advance directive is often not in the right place at the right time, says Ronald Costen, PhD, Esq, a professor and director of the Institute on Protective Services at Temple University. “The hospital or facility may never be provided the document, even if it exists, and so it is not honored,” he says. “I think the POLST movement has emerged as a way to make sure those wishes are not only known but entered as a medical order and followed by healthcare professionals.”

Besides turning an elder’s wishes into a doctor’s order that healthcare professionals take seriously, POLST also has a physical difference: It’s a brightly colored form that’s hard to miss. It remains with the patient, perhaps at the top of his or her chart, or in another highly visible place. If the patient is on hospice at home, it’s often kept on the refrigerator where EMS personnel can access it. The state of Oregon, which is highly advanced in its use of POLST, has gone a step further and created an electronic registry where forms are logged. No matter where the patient goes, the form is quickly and easily accessible.

A Difficult but Critical Conversation
So how does someone go about completing a POLST form? The paperwork is filled out by a healthcare professional and becomes an actionable medical order when signed. A physician usually signs the form, though some states allow a nurse practitioner or a physician assistant to sign it. In an ideal situation, in a state that offers POLST, a patient being admitted to a nursing home would sit down with his or her family, the geriatric care manager, and a physician to create the specific orders for the form. “Children who live in another city are typically present when the parent is moved into such a facility,” says Tolle. “This is really the best time for the conversation to be had and the orders to be created.”

One potential roadblock that has emerged is the concern that physicians don’t have the time to discuss lengthy end-of-life specifics with each patient. However, advocates of POLST say it’s easier for everyone when specifics are handled in advance. “Physicians who are familiar with a POLST program find that in crisis, having had the conversation up front allows them to best respect their patients’ choices,” says geriatrician Judith Black, MD, MHA, senior markets medical director for Highmark, Inc. Highmark identified improving care for end of life as an initiative in 2000, and Black has been leading that initiative. “As a practicing geriatrician, one gap in care was ensuring wishes were respected across care settings, and POLST is a program to help ensure wishes are respected.”

This advanced planning also helps relieve a lot of the burden on families, ensuring the best choices are made and there is no confusion over what to do. “If a change in the patient’s health happens very quickly, it can be a difficult and emotional time for the family,” says Marian Kemp, senior markets project manager for Highmark. “Having to make decisions in a time of crisis is overwhelming. But with POLST, you know exactly what the patient’s wishes are.”

Because POLST is a living document, it can also be changed at any time. “Patients can certainly revisit their POLST form should their health status or wishes change,” explains Tolle. “If they get better, they may want more treatment options. Oftentimes, in reality though, the patient gets sicker and wants to change their form to add more limitations and restrictions. But it’s a process and a lot of people have more than one form. Unlike an advance directive, which was written decades ago and left untouched, patients are more actively involved in updating their POLST form.”

While it can be a difficult conversation to have, Tolle says it is the compassionate thing to do for both the patient and the family. “POLST helps [the family] when that call comes in at 2 am saying that Mom has developed pneumonia,” she says. “What to do has already been spelled out, and everyone is on the same page. So instead of asking difficult questions in the middle of the night, the call would just let the family know that their mother had indicated on her POLST form that she wants to receive antibiotics but does not want to be admitted to ICU and that those wishes are being followed. That relieves a lot of stress.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.