Monday, September 25, 2017

By: AMFS Internal Medicine & Medical Ethics Specialists 

POLST stands for Physician Orders for Life-Sustaining Treatment and is a document that stipulates portable orders for resuscitation, relative aggressiveness of treatment and/or artificial nutrition for patients with serious, but not necessarily terminal, illness. POLST paradigm programs exist in 47 or the 50 states – at this point absent only from Arkansas, Mississippi, South Dakota and the District of Columbia. Interestingly, POLST paradigm documents actually go by different acronyms in different states – MOLST in New York, POST in West Virginia, but with most states using the name, POLST. Veterans administration medical centers use the unique term, State Authorized Portable Orders (SAPO), and require its facilities to utilize forms and programs in their relevant states.

POLST began in Oregon in 1991 as a means of better coordinating the care of patients living in nursing homes who characteristically move in a cycle of nursing home – emergency room – intensive care unit, even though such interventions might be seen as burdensome and unwanted by some patients and/or loved ones. What ensued was a process by which at this point in time it is nearly universal for nursing home patients in Oregon to have such a document. This process has been adopted enthusiastically across the United States, though most states are significantly less developed in their implementation as yet.

The creation of a POLST document, which requires the signatures of both healthcare provider (Physician in some states, physician extender in others) and patient or surrogate decision maker to be valid, also requires that an in depth conversation has occurred in which patient and provider come to a meeting of the minds about what exactly should be done for end of life care. A POLST order set takes effect immediately, unlike an Advance Directive form, which usually stipulates that “if such and such were to occur, I would not want life sustaining treatment.” Additionally, POLSTs are designed, as medical orders, to be fully honored throughout its state – by paramedics, hospitals, even healthcare facilities unfamiliar with the physician signing the form. Perhaps unique among written medical orders, a POLST may be instantly revoked at a patient’s request. For all these reasons, a POLST form is not an Advance Directive. Additionally, It may use a health care agent, but does not formally appoint one.

While designed to help coordinate care, it is not uncommon for conflict to ensue in the hospital setting in regards to POLST forms. Patients and their providers may make plans that are completely unknown to families – and they may understandably object. While surrogate decision makers are technically usually legally prevented from overturning POLST orders for end of life treatment created by providers and competent patients, it is not unusual for physicians to bend to the will of upset families. This type of conflict is best managed by hospital ethics committees who typically have significant experience in this exact type of dilemma. This issue is of course, exactly analogous to conflicts that have been occurring regarding the implementation of Advance Directives for decades.

Barring such scenarios, POLST typically helps ensure that “The right patient gets the right care at the right time.” Because POLST allows for a full range of treatment choices, from fully aggressive treatment, to comfort care only – with or without further hospitalizations, POLST can accommodate any patient and/or surrogate decision maker. The unique contribution of the healthcare provider is in educating and guiding such that they can feel good about ordering end of life treatment options that are realistically likely to be helpful, and not harmful.