The way Charles ultimately passed wasn't how he'd wanted to go.
A 90-year-old resident of Longview, Washington, diagnosed with Parkinson’s Disease, Charles signed a “do-not-resuscitate” (DNAR) order. Yet when his heart stopped beating during surgery to repair a fractured hip, doctors performed compressions hard enough to crack his sternum. He was placed in the ICU, connected to a breathing machine and feeding tube, and kept in a coma-like state—against the wishes he had previously expressed in writing. Charles spent the next six weeks living in severe pain before he passed.1
Charles’s case highlights the benefits, and limitations, of a document known as a “physician orders for lifesustaining treatment” form, or POLST form, in Oregon and Washington. (It’s known by different but similar names in other states.)
While patients often have advance directives that express their personal philosophies about future care, a POLST form is a medical order for the specific medical treatments patients want if a medical emergency happens today. POLST forms are appropriate for individuals with a serious illness or advanced frailty near the end of life.2
POLST forms were first developed in Oregon in the 1990s. While all states are now adopting the form to some degree, “There is significant state variability in their adoption,” says Dr. Susan Tolle, M.D., Director of the Center of Ethics in Healthcare at Oregon Health and Science University (OHSU) and Chair of The Oregon POLST Coalition. “Some states have very mature POLST programs and widespread use of the forms, and other states are still developing a program.”
Ideally, Tolle adds, POLST forms should be readily available for those who want them and are nearing the end of life.
For an overview of POLST that you, your patients, and their families can watch, see “POLST: When Is the Right Time?” on YouTube at: https://bit.ly/2KAIf5C.
POLST forms and advance directives work together. Considered a legal document, advance directives enable patients to indicate their general wishes about treatment and to appoint a surrogate. However, these directives need be turned into action with medical orders to ensure that patient wishes are honored by emergency medical personnel.
As specific medical orders, on the other hand, POLST forms can be found in electronic medical records, accessed by all health-care personnel, and listed in a state registry. In efforts led by Dr. Tolle, Oregon has been instrumental in making POLST forms accessible in patient medical records with a single click.3Technology integration is critical, according to Dr. Tolle. “We are encouraging a one-click immediate access, separate from advance directives, so health-care professionals see it immediately when they open a patient chart,” she says. “In a growing number of Oregon hospitals, patient records display a ‘POLST YES’ or ‘POLST NO’ on the header, so the document is not buried with other correspondence. This ensures that in a crisis, health-care professionals are far more likely to find it and follow its instructions.”
WHEN TO FILL OUT A POLST
It’s not accurate to say that all elderly patients need POLST forms. According to the National POLST Paradigm, POLST forms are recommended for patients who are seriously ill or frail (at any age) and whom health-care professionals believe may die within one year. In fact, a study conducted in Oregon determined that more than half of POLST forms were completed within the final two months of life.4
And there’s a risk in filling out the POLST form too early. According to Tolle, “At times, health-care professionals are filling out POLST forms with patients when they are not POLST-appropriate. These people are healthy, so they would indicate on the forms that they want full treatment. As a result of the wrong timing, a few patients have had unexpected consequences, such as being denied life insurance when they are still in good health. They should have an advance directive, of course, but wait until they’re sicker to complete a POLST form.”
THE CONTROVERSY SURROUNDING POLST
POLST forms have been gaining acceptance across the country. However, the idea of POLST is controversial in some circles. In 2013, the Catholic Medical Association published a paper raising concerns about the moral and ethical issues associated with POLST, suggesting that its use “advances the idea that disability and dysfunction can reduce the value of a person’s life,” which is seen as a contrast to the values of Catholic health care.5
In 2016, the Journal of the American Medical Association (JAMA) published a paper whose authors argued that standing physician orders on a POLST form “may actually curtail patient-centered decision making when applied more broadly. Standing physician orders that dictate future treatment decisions are appropriate only if preferences are stable over time and across foreseeable clinical contexts.”6
Tolle counters that a POLST form, used correctly, truly reflects the patient’s wishes. “We need to be sure it’s filled out appropriately. If a patient is living life’s last chapter, and if they have a deep desire not to spend it in intensive care, then they need to make a plan that is recorded as medical orders. Otherwise, the default is the hospital. I want the conversations around POLST to be deep and thoughtful.”
HAVING CONVERSATIONS WITH PATIENTS AND THEIR FAMILIES
As with many common medical decisions, primary-care physicians should talk with their sicker patients about advance-care planning and POLST, even if a form isn’t completed right away. Ideally, patients would have already set up the legal documents of their advance directives and appointed a surrogate during healthy years (often with the help of a family law professional). Then later, as their health declines, their physician can complete the POLST to provide actionable direction in line with their wishes.
“If you have these conversations with your patients as they become more frail, and stay a bit ahead of the game, it will be a gradual and well informed process for patients and their families,” says Tolle. “Otherwise, it can be very stressful for everyone involved. Think of families traveling cross-country in a hurry and having to get up to speed quickly on a loved one’s condition. The quality of the decisions may not be as good, and the frail elder may not be able to fully participate because you waited too long.”
POLST VARIATIONS BY STATE
POLST forms and guidance vary by state. In addition, the name and acronym used for POLST programs may also differ slightly. For more information on state-specific programs, visit their respective websites:
Alaska (MOLST—Medical Orders for Life-Sustaining Treatment)
Currently under the auspices of the Alaska Pioneer Homes
Idaho (POST—Physician Orders for Scope of Treatment)
Oregon (POLST—Physician Orders for Life-Sustaining Treatment)
Washington (POLST—Physician Orders for Life-Sustaining Treatment)
Wyoming (POLST—Provider Orders for Life-Sustaining Treatment)
1 “Local Patient Died in Pain After Do-not-resuscitate Wishes Were Ignored.” Accessed at https://tdn.com/news/local/local-patient-died-in-pain-after-do-notresus…
3 “In Oregon, End-of-Life Wishes Are Just a Click Away.” Accessed at https://khn.org/news/in-oregonend-of-life-wishes-are-just-a-click-away/
4 Zive, DM, EK Fromme, TA Schmidt, JNB Cook, and SW Tolle. “Timing of POLST Form Completion by Cause of Death.” Journal of Pain and Symptom Management 50(5):650-658 (2015).doi:10.1016/j.jpainsymman.2015.06.004.
5 “The POLST Paradigm and Form: Facts and Analysis.” Accessed at http://forum.cathmed.org/assets/files/POLST_Paradigm_and_Form.pdf
6 “The Problems with Physician Orders for Life-Sustaining Treatment.” Accessed at https://jamanetwork.com/journals/jama/articleabstract/2482337