Physician Orders for Life-Sustaining Treatment

Summary

POLST (Physician Orders for Life-Sustaining Treatment) is a new approach to improving end-of-life care by encouraging doctors to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis. POLST began in Oregon in 1991 and is currently promoted in over 26 states through national and statewide initiatives. The POLST document is a standardized, portable, brightly colored single page form which documents a conversation between a doctor and a seriously ill patient or their surrogate decision-maker. As a medical order, the POLST form is always signed by a doctor and, depending upon the state, the patient. One benefit of a POLST form over a standard Advance Directive is that the POLST form is designed to be actionable throughout an entire community. It is immediately recognizable and can be used by doctors and first responders (including paramedics, fire departments, police, emergency rooms, hospitals and nursing homes). POLST forms should be filled out for all patients with life-limiting illnesses or progressive frailty. A pragmatic rule for initiating a POLST can be if the clinician would not be surprised if the patient were to die within one year.

POLST orders are also known by other names: medical orders on life-sustaining treatment (MOLST), medical orders on scope of treatment (MOST), or physician’s orders on scope of treatment (POST).

What is POLST?

POLST represents a significant paradigm change in advance care policy by standardizing provider communications through a plan of care in a portable way, rather than focusing solely on standardizing patients’ communications via Advance Directives.

The POLST paradigm requires providers and patients or their surrogates to accomplish three core tasks:

• First, POLST requires a health care professional to initiate a discussion with the patient (or the patient’s authorized surrogate) about treatment options in light of the patient’s current condition.

• Second, the patient’s preferences for end-of-life treatments are incorporated into medical orders, which are recorded on a highly visible, standardized form that is kept at the front of the medical record or with the patient if the patient lives in the community.

POLST forms record several treatment decisions common to seriously ill patients: cardiopulmonary resuscitation; the level of medical intervention desired in the event of an emergency (comfort only, limited treatment, or full treatment); and the use of artificial nutrition and hydration. Some states address additional interventions such as antibiotics and mechanical ventilation. As technology and treatment options change, POLST forms will also continue to evolve.

• Third, providers encourage that the POLST form travels with the individual whenever he or she moves from one setting to another, thereby promoting the continuity of care throughout a community.

The POLST form is designed to transfer across treatment settings, so it is readily available to medical personal, including EMTs, emergency physicians and nursing staff. The POLST Program relies upon teamwork and coordinated systems to ensure preferences are honored throughout the heath care system. Research suggests the POLST form accurately represents patient treatment preferences the majority of the time and that the treatments provided at the end of life match the orders on the form. An established POLST program can help reduce unwanted hospitalizations and honor the patient’s end-of-life wishes. (MEIER)

To determine whether a POLST form should be completed, clinicians should ask themselves, “Would I be surprised if this person died in the next year?” If the answer is that the patient’s prognosis is one year or less, then a POLST form is appropriate. (Dunn, Tolle, Moss, Black)

In a 2006 consensus report, the National Quality Form observed that “compared with other advance directive programs, POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals.” The National Quality Forum and other experts have recommended nationwide implementation of the POLST Paradigm ( (hikman 16)National Quality Forum, A National Framework and Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report, 2006, at 43. A. Kellerman and J. Lynn,)

Differences Between an Advance Directive and a POLST Form

Unlike advance directives, a POLST summarizes the patients’ wishes in the form of physician orders for end-of-life care. (freiden)

POLST provides explicit guidance to health professionals under predictable future circumstances(Meier). POLST can build on an advance directive but can also function in the absence of an advance directive. If the individual lacks decisional capacity, a surrogate can engage in the conversation and the consent process that forms the basis of the POLST process.

Table 1: Summarizes Key Differences Between POLST and Advance Directives. (AARP)

The challenges that patients, families and their healthcare professionals face at the end of life can be daunting. Caring and sensitive communication can elicit patients’ wishes which can then be documented in an advance directive. To put these preferences into actionable orders requires an additional tool, the POLST form. Healthcare professionals and their organizations can overcome the myriad barriers to communication across systems of care by developing a POLST program, creating a method that respects some of the most deeply held values of patients. (Dunn, Tolle).

History • 1991: Oregon POLST Task Force Created • 1995: First POLST form used in Oregon • 2004: National POLST Paradigm begins • 2006: West Virginia and Wisconson adopt POLST • 2009: POLST becomes law in California and New York • 2012: National POLST Conference in San Diego, CA

(OHSU)

POLST Research

• In a 1998 study, charts of 180 residents at eight Oregon nursing facilities were evaluated over a one-year period. Where the POLST forms of residents included “do not resuscitate” and “comfort measures only” orders, none of the residents received unwanted cardiopulmonary resuscitation (CPR), intensive care, or ventilator support. (10)

• In 2004, a survey of selected sites revealed that the POLST program was widely used in Oregon nursing facilities. Care matched POLST instructions to a high degree regarding CPR (91%), antibiotics (86%), intravenous fluids (84%), and feeding tubes (94%). Level-of-care instructions (from comfort care to full medical intervention) were followed less often (46%). 12

• A 2004 survey of 572 EMTs in Oregon found that a large majority of EMTs felt that the POLST form provides clear instructions about patient preferences and is useful when deciding which treatments to provide.

• In 2009, researchers assessed the penetration of POLST in hospice programs in Oregon, Wisconsin, and West Virginia. (14) A pilot study indicated that POLST was used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff believed POLST was useful in preventing unwanted resuscitation and initiating conversations about treatment preferences. (AARP) (10

Op. cit., 7 
S. W. Tolle, V. P. Tilden, P. Dunn, and C. Nelson, “A Prospective Study of the Efficacy of the Physician Orders for Life 

Sustaining Treatment,” Journal of the American Geriatrics Society, 46, no. 9 (1998): 1097–1102. 12

S. E. Hickman, S. W. Tolle, K. Brummel-Smith, and M. M. Carley, “Use of the Physician Orders for Life-Sustaining Treatment 

Program in Oregon Nursing Facilities: Beyond Resuscitation Status,” Journal of the American Geriatrics Society, 52 (2004): 1424–29. 14

S. E. Hickman, C. A. Nelson, A. Moss, B. J. Hammes, A. Terwilliger, A. Jackson, and S. W. Tolle, “Use of the Physician Orders 

for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting,” Journal of Palliative Medicine 12, (2009): 133–41.)

Future Goals

Susan Tolle M.D. and Patrick Dunn, M.D. are faculty at OHSU’s Center for Ethics in Health Care and provide support to those who wish to spread Oregon’s POLST Paradigm to other states.

Core features of successful programs include the robust ongoing training and education of health professionals. Communication skills and a commitment to improving end-of-life care are needed to implement POLST in a patient-centered, meaningful way. Ongoing monitoring, quality improvement and further research is critical to expand and improve the POLST process.

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