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 [email protected]
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