Commentary: Know Your POLST
By Karen Ward, RN
POLST (Physician Orders for Life-Sustaining Treatment), also called POST (Physician Orders for Scope of Treatment) and MOST (Medical Orders for Scope of Treatment), is incrementally making its way across the U.S.
What is POLST? A physician's preprinted order sheet with check boxes to choose NO IV, antibiotics, do not resuscitate, and other treatment wishes, or lack thereof.
"Means To A Better End: A Report on Dying In America Today" was published in 2002 that hailed a state by state analysis by the now defunct Last Acts organization. Data allegedly did not exist until this report was published.
POLST is described on page 75 of this report and is part of the SUPPORT Study funded by the Robert Wood Johnson Foundation (RWJF). Last Acts Committees and Advisors include Right to Die (RTD) supporters, and are listed on pages 96 and 97 of this report.
Myra Christopher's Center for Practical Bioethics introduced the concept of POLST to End of Life and Right to Die supporters in the Robert Wood Johnson Foundation's (RWJF) Community State Partnership initiative #3. That initiative specifically states POLST prevents unwanted, aggressive life sustaining
treatment by Emergency Medical Service personnel.
Does it do the job it was intended for?
If so, the EMS problem ought to be resolved. Advancing assisted suicide laws and hastening death by use of this form is totally contraindicated to its original development and purpose.
POLST was developed by Oregon EOL proponents with the claim there was no legislative inclusion; however, we now know POLST has been created by statutes, regulations and legal guidelines; but mostly by state statutes.
POLST has taken time to implement in this country and is controversial. The best state in which to implement the form was Oregon, with assisted suicide laws already on the books. RTD supporters enthusiastically approve of POLST.
Advance Directives and Living Wills were initially developed and touted as a method for people to control, have say over, and provide autonomy in their medical decisions and treatment. They have both proven ineffective, due in part from failure to utilize them and understand them. Even if utilized, physicians do not always follow them for obvious reasons.
In response, the POLST (Physician Orders for Life-Sustaining Treatment) model was developed with RTD input that consists of physician orders that are converted into patient treatment preferences and clinical treatment. They are actually preprinted orders with specific boxes that are checked.
Do these forms encourage people to use and increase the numbers of people that use Advance Directives and Living Wills? Will these forms become governmentally mandated? Will these forms become standard hospital policy? Will they evolve to all patients' charts?
Is the goal to phase out current Advance Directives?
If not, what is the rationale of duplicity and probable conflict of the 2 forms?
If POLST is to enhance Advance Directives, which one supercedes the other?
Which one is followed if there are discrepancies?
Can only specific portions of POLST be singled out and followed without creating problems?
How are only pieces and parts of 2 separate forms understood, much less followed, or legally binding without a patient's signature?
Many people are adamantly opposed to current Advance Directives and Living Wills due to inefficient use and confusion by the public and healthcare personnel. They also present confusion and unclear specificity as to decisions by patients in complicated medical conditions and when those health conditions change.
Whether patients make concessions for specific treatments in specific circumstances or not, physicians know when most patients have a good prognosis, and therefore hesitate to follow patients' Advance Directives, if withholding treatment will cause harm. They do not want to withhold treatment causing death when this patient will survive and lead a productive and normal life.
The major benefits realized with a document of this type are that 1) information about the patient's treatment preferences is condensed, handy, and appears to be understandable in physician order format and 2) continuity of patient care is increased, if they are updated and followed, and not used as a means to justify assisted suicide or hasten death.
That said, how will POLST 1) improve existing documents thereby allowing patients the ability to maintain autonomy over their clinical care,
2) reassure patients their decisions will be carried out without neglect, abuse, and exploitation,
3) resolve issues we currently face, such as familial conflicts in following patient decisions and physician/nurse conflicts in following patient decisions,
4) maintain the integrity of the medical professions, and
5) protect the medical professions from liability, without usurping our ethical standards and oaths as apply to medicine and medical caregivers' morals systems?
The medical field concerns are listed below.
1) Medical or physician orders are converted into legally binding patient treatment decisions or preferences. In some instances, these decisions and clinical care provided may go against standards of care and professional oaths. As well, patient preferences are often not followed. Will this form improve effectiveness of patient preferences, but at the same time, prevent the physician from adequately treating a patient with a good prognosis?
EXAMPLE: 70 year old with history of high blood pressure, gastric ulcer, and alcohol abuse, including recent loss of spouse is admitted with toxic megacolon presenting with fever, dehydration, hypotension and tachycardia. Will this patient receive life saving treatment, such as IV fluid replacement, if POLST is enacted, and comfort measures and DNR boxes are checked?
2) Broad based language allows for different interpretations. The options and check boxes provided on the form are so broad based that any medical condition or problem which arises with a good prognosis or outcome leaves not only uncertainty as to how to treat, but the potential for liability if the decision is made not to treat.
EXAMPLE: 64 year old with history of peripheral vascular disease, mild cognitive impairment, and anxiety admitted with lethargy and severe dehydration after prolonged sun exposure. Patient displays difficulty with wor
ds and communication. Will this patient receive life saving treatment if POLST is enacted, and no IV fluids box is checked?
3) Impossible to foresee and plan for unexpected and acute illnesses and diseases which are in a constant state of flux, particularly with the elderly that often have myriad health problems.
EXAMPLE: 80 year old with history of congestive heart failure, diabetes and frequent urinary tract infections admitted with renal calculi and possible pneumonia. Will this patient receive treatment if POLST enacted, and comfort measures, no antibiotics, or no IV fluids boxes checked?
4) The general public is not knowledgeable on medical care, diseases, and treatments, and therefore decisions on withholding life saving treatments may not always be in the patients' best interests. Often, to the layperson or non-medical individual, life support and life sustaining treatment is a judgment predicated on their medical knowledge base and perceptions about what this all entails.
EXAMPLE: 56 year old with history of heart attack X1 with 2 subsequent stent placements admitted for yearly cardiac workup. Patient states to sister, "I don't want one of those tubes that Aunt Bertha had rammed down her throat. Forget the CPR if you just lay there and can't talk" Will this patient receive life saving
treatment, including CPR and possible intubation, if POLST enacted and DNR checked?
For those who believe people know how to make appropriate decisions in their health care, let's prepare a short quiz and poll, administer it to a random sampling population, and we can analyze the data; only then can we draw firm conclusions on public knowledge and appropriate decisions in medical treatment decisions.
5) If POLST is made mandatory in clinical care and treatment, patient autonomy is taken away from the patient and their Medical or Healthcare POA. What role does the Medical POA have when POLST is enacted? Do they have the authority to change the POLST thereby denying treatment when the patient is unable to communicate changes to the form? Does the physician have the authority to change the POLST?
Can a healthcare facility or physician refuse to honor a POLST?
6) With POLST, the onus is put on physicians or nurses to ask and clarify treatment decisions. While this is appropriate in some circumstances, decisions regarding clinical treatment, particularly life support, and controversial withholding of some medical treatments is best discussed, defined and characterized by the
patient, their family, their Medical DPOA's, and their lawyer before they enter a healthcare facility. We simply cannot be held accountable, nor can we rescind presumed consent for clinical treatment when we provide the document, and then attempt to discern a patient's decisions when they cannot communicate,
their condition changes, or treatments are not covered under this document. Patients frequently do change their minds. When we fail to follow or follow standard medical treatment that the patient feels should not be
followed, liability issues could easily arise. The facility and caregivers enacting the form are at risk when family disagrees as to treatment then provided.
Further, since the patient is not required to sign the document, the only signatures on the forms are the physician and/or the nurse when initiating the form.
In some situations, the patient will not be established with the physician and they may not even know each other. Often, the forms will be put on the chart, initiated by the nurse, and when the physician signs, will put their signature to life and death treatment and decisions without ever being present when the form was discussed with the patient.
EXAMPLE: 49 year old mildly retarded with cerebral palsy recently lost elderly parents, now living with oldest sister out of necessity admitted for trauma status post automobile accident requiring emergency surgery to repair fractured hip. Will this patient receive life saving treatment, if POLST enacted by sister denying antibiotics, or patient is unable to understand clinical treatment decisions on POLST form believing comfort box means nurse administering Tylenol for her migraines? Another family member then has the ability to sue the hospital; specifically the nurse and physician whose names are on the POLST form.
Patient signature and sister signatures are absent.
7) Current Advance Directives very possibly may conflict with POLST forms. Which one then takes precedence over the other and is followed? If two forms are present, how does a physician choose which one to honor, particularly in an emergent situation? POLST also adds another document to the admission
process and to physician orders. We need less complexity, not more.
8) Nurses do admission summaries on all patients EACH time they are admitted to a hospital, including whether the patient has an Advance Directive. The rationale behind this is that medical conditions change. So, we anticipate patients will change their minds about enacting POLST, just as they do Advance Directives. Will the POLST also be reassessed with each admission? If not, this will be the only medical form not updated with each admission? Liability is a major issue when using obsolete information on old forms describing medical treatment likes and dislikes in the face of changing health conditions.
9) All persons are potential patients—regardless of age—due to accidents, trauma, and disease. Not all are life threatening or terminal from a clinical perspective. For those finding themselves in an acute care setting via ER and unable to communicate, when is POLST enacted and by whom, in order to preserve patient autonomy? Does the family, physician, healthcare facility or other enact POLST in this situation? Sometimes, medical indications will override patient preferences. Do we ignore life saving treatment due to patient preferences based on unsound medical knowledge and judgment on the part of the patient? Depression is also a factor to consider.
EXAMPLE: 79 year old patient with history of depression and adult onset diabetes under control undergoing emergency appendectomy has a cardiac arrest on the OR table. Will this patient be resuscitated if POLST enacted which has DO NOT RESUSCUTITATE checked?
10) It is unethical to enact POLST without educating the public, and even more so without educating medical professionals. In one healthcare institution, a quick survey was recently taken. One RN and two MD's out of 49 in total had accurate knowledge about POLST. None could describe anything about POLST. Some guessed and said it probably was to clarify or replace an Advance Directive. All had questions about the form.
11) Since the majority of these forms indicate DNR status, comfort care only, limited interventions, whether to provide treatment with antibiotics, and limited or no nutrition and hydration, we question if these forms were originally developed for patients near death or terminally ill.
If the form is not just for the terminally ill, how do we protect patients from exploitation and abuse by their surrogates if enactment of POLST is attempted?
If the form's intent is for the terminally ill, will they be adapted into the whole of medicine and used on those with chronic conditions?
If so, the form is not applicable in many healthcare settings. Also, the potential for misuse and abuse when POLST is applied to any patient in any healthcare setting by healthcare professionals and Medical DPOA's must always be a concern.
When a patient's clinical picture changes, what is the role of the surrogate in decision making utilizing POLST? Is there an oversight or regulatory agency, a complaint form, hotline, or other
regulatory agency setup in place to refer questions, problems, complaints, and resolution of issues outside the facility? Or will problems go unreported, undetected, and with few facts released to the public, as we currently see in the Oregon statistics on assisted
12) Legally binding boxes are checked off on a form as to whether to provide treatment or withhold life saving medical treatment with nurses' names attached to the form. What are the liability issues to the nurses?
The patient is entitled to a copy of POLST so they can review it and make any revisions once they ponder their responses. They may also want to discuss their decisions with family, friends, and their DPOA.
Without a copy, they are unable to do so.
Culling key elements of an Advance Directive to include on the abbreviated POLST form that initiates a consistent plan of care is only useful to the imminently dying. If this form were accidentally added to a surgical patient's chart, that patient could be denied life saving treatment. If the rationale is decreasing the number of days a patient spends in ICU or a hospital, withholding treatment for this purpose is not a justifiable reason to utilize this form, sets the stage for abuse, neglect, and exploitation, and could be called substandard medical treatment. The insurance companies may like it, but as a patient and healthcare giver, there is no sound rationale for use when treating patients in a clinical and curative environment.
By using key elements of Advance Directive forms in POLST, there is no guarantee a greater number of patients will fill out Advance Directives, unless they are misled to believe this form is standard for all charts, when in fact it is not applicable to all patients' conditions. If a patient is dying, hopefully they have discussed with their physician and put their dying wishes on paper that which pertains to their condition, unless their condition is an unexpected
accident or acute and life threatening condition.
Then there is the duplicity factor which is sure to create confusion among all. There is also the issue of surrogates that abuse, neglect, and exploit their charges. Who monitors problems, complaints, and abusive issues with current HIPPA regulations in place? Medical facilities would love the anonymity, but patients who are harmed and die have no recourse, and their families are denied justice. Look to the Oregon model on assisted suicide for problems with
unknown statistics, as an example.
A model policy or protocol is not achieved by implementing pieces and parts of an ineffective Advance Directive. If the rationale is to develop a model policy for end of life, each specific issue needs addressed and remediation implemented. There is no rationale that concludes use of this form purposely decreases the numbers of nursing home patients experiencing pain.
While some argue that patients in a nursing home are at their end of life, that does not mean we set up a policy to hasten their death by POLST. We know this will happen, as it currently happens, and without use of the POLST form. This form will not change these harmful acts. This form may actually encourage and provide a legalized method of hastening death and assisted suicide, but if this is the intent of the form, we, the public, have been deceived.
Identification of state and federal laws and regulations limiting palliative care creates a whole new area of abuse, neglect, and exploitation by allowing greater ability to implement assisted suicide and this by using the field of medicine to pass it off to an unknowing public.
All nursing home patients could then be transferred to hospice service, put under palliative care protocols or policy, and then given only end of life care; high doses of opioids, and without curative treatments, including no antibiotics for pneumonia or lack of treatment for gallstones or other medical conditions. While palliative care guidelines are observed, high numbers of patients will die due to lack of treatment or treatment omissions.
Diseases such as cardiac conditions, asthma, or diabetes do not necessarily make an imminently dying patient, nor should patients be categorized as having life threatening diseases that are chronic in nature.
Patients should not be forced to fill out POLST that limits their treatment options, especially if they have several chronic diseases that are expected to worsen over time. Failure to explain this to the public is deceitful.
Healthcare personnel and employees should not be mandated to fill out an Advance Directive. A broader use of Advance Directives is a goal, not of medicine, but of Right to Die (RTD) proponents who have spent many years changing public policy by changing medical policies. If the medical field does not feel comfortable using the POLST form, it should not be used, even on dying patients near their end of life in order to hasten their death.
The concerns above are valid.
The scenarios above are a glimpse of constant occurrences in hospital settings. There is too much wiggle room on the forms which prevent and hinder proper medical care delivery to all patients across the healthcare spectrum. The
chances for mistreatment and maltreatment are significant. The liability issues are great concerns among healthcare professionals.
POLST was introduced during the 2006 legislative session in the state of Florida. There were so many concerns brought forth that the bill was pulled. When it passes in future remains unclear, but passage is almost certain.
What is clear is that POLST advocates will reintroduce the POLST bills again and again, until they pass. Some states have POLST enacted, and there are still many concerns not addressed and many unresolved. We know the POLST forms are not uniform in nature and have loopholes that can create problems in the future for our patients.
The POLST Task Force emphasizes that the POLST form is not an Advance Directive, which means that in many states it is not bound by state Advance Directive statutes which often require a patient's signature.
EOL advocates want to add another form to palliative care that prevents medical treatment and state legislatures are willing to comply.
The history of POLST, key elements, the form itself, and other information, both pro and con, can be found at these web sites.
Karen Ward is a Registered Nurse in Florida and holds a license in Ohio. North Country Gazette