POLST Offers Next Stage in Honoring Patient Preferences

Abstract

National advocacy groups have spent considerable effort promoting advance care planning and encouraging completion of advance directives in order to enhance congruence between the kind of medical care people say they would want to receive during serious or terminal illness and the care they typically receive. These efforts continue despite a growing body of evidence suggesting that conventional advance directives have not been as helpful as proponents hoped. A new and rapidly diffusing approach to ensuring care concordant with patient preferences, executed closer to the time of need, is called the Physician Orders for Life-Sustaining Treatment or POLST. POLST translates patient preferences into specific medical orders to be honored by physicians and other health care workers during a medical crisis. POLST advocates emphasize that this approach, first developed in Oregon in 1991 and recently adopted statewide in California and New York, is not an advance directive but rather is a set of medical orders. An advance directive is a legal document, such as living will or durable power of attorney for health care decisions, which is completed far in advance to inform a potential future medical circumstance in which the individual may be incapable of making decisions or expressing preferences for care. POLST, by contrast, is a medical order signed by a physician, after consultation with the patient or—if the patient lacks capacity—with the patient’s legal surrogate. POLST is appropriate for people who already have an advanced chronic illness, for whom the prognosis is measured in 1 to 2 years. It specifically addresses medical decisions and options that are likely to arise in the near future, including cardiopulmonary resuscitation, antibiotics for infections, artificial food and fluids, and whether or not the patient would want to be rehospitalized. More relevant and specific than conventional advance directives, POLST provides explicit guidance to health professionals under predictable future circumstances (such as development of pneumonia in a patient with advanced dementia). (See Fig. 1 for an illustration of a POLST form.) The Center for Ethics in Health Care at Oregon Health & Sciences University (OHSU) describes POLST as a new paradigm for the health care system. The center established the National POLST Paradigm Initiative Task Force (see www .polst.org) to facilitate the development, implementation, and evaluation of POLST initiatives nationwide. Subsequent to the Oregon initiative, a number of states have implemented POLST programs, either statewide (Idaho, New York, North Carolina, Washington, and West Virginia) or as regional or community projects. Others are exploring POLST coalition building, dissemination and implementation, with consultation, facilitator training and technical assistance from OHSU. (See Fig. 2 for a map showing participating states.) The basic POLST approach provides actionable information on how to honor the wishes of a patient with a lifethreatening condition regarding a range of available medical treatments; documents those wishes in a physician-signed medical order on a brightly colored (typically pink) form that accompanies the patient across and between settings of care, including ambulance rides; and formalizes agreement by health professionals across all settings in the community to honor medical orders contained in the POLST form. Experts emphasize that POLST is not just a glorified donot-resuscitate (DNR) order. Patients with POLST may indicate their desire either for or against specific life-sustaining treatments, and may endorse different combinations of relevant treatments. According to one study in Oregon, a majority of patients requesting DNR via POLST actually wanted potentially life-prolonging interventions in at least one other treatment category. (For example, a nursing home patient’s POLST might specify no rehospitalization and no cardiopulmonary resuscitation [CPR], but request antibiotics in case of infection, and tube feeding for nutrition and hydration.) Through its specificity and provision of yes-or-no answers for each of the common decision points (hospitalization, CPR, intensive care, ventilatory support, artificial nutrition and hydration) POLST provides quick and clear guidance to any health professional who simply reads the single-page form. Patients may also revoke an old POLST form and write a new one as their disease and other circumstances change. When combined with state policies and=or legislation recognizing the document as a valid medical order and broadbased education for health care professionals on how it works, POLST can convert patient preferences into immediately actionable medical orders that are readily accessible to medical