What is a Physician Orders for Life-Sustaining Treatment (POLST)?

Physician Orders for Life-Sustaining Treatment (POLST) is a medical order that outlines a plan of care reflecting the patient's wishes concerning medical treatment in their current state of health. Unlike traditional advance directives, which are often general and meant for future scenarios, POLST forms are intended to be actionable medical orders that provide specific instructions for healthcare providers during emergencies.

History of POLST

The concept of POLST originated in the early 1990s in Oregon as a response to the need for more explicit and effective ways to ensure that patients' end-of-life care preferences were honored. Traditional advance directives often failed to translate into actionable medical orders, especially in emergencies. The initiative aimed to bridge this gap by creating a standardized form that could be easily recognized and followed by healthcare professionals.

Purpose and Goals

The primary purpose of POLST is to ensure that patients receive the type of medical treatment they desire, especially during emergencies when they cannot speak for themselves. The goals of POLST include:

1. Enhancing Patient Autonomy: POLST empowers patients to make informed decisions about their medical care and ensures these decisions are respected across various healthcare settings.
2. Improving Communication: By providing clear and concise medical orders, POLST facilitates better communication between patients, families, and healthcare providers.
3. Ensuring Continuity of Care: POLST forms are designed to be portable and recognized across different healthcare facilities, ensuring that patients' wishes are followed consistently.

Key Components of POLST

A typical POLST form includes several key components:

1. Patient Information: Basic information about the patient, including name, date of birth, and contact details.
2. Medical Orders: Specific instructions regarding life-sustaining treatments such as cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition, and hydration.
3. Signatures: Signatures of the patient (or their legally authorized representative) and the healthcare provider, affirming the authenticity and agreement on the outlined orders.

Sections of the POLST Form

The POLST form is generally divided into sections that address different aspects of medical care. These sections may vary slightly depending on the state or region, but typically include:

1. Cardiopulmonary Resuscitation (CPR): This section specifies whether the patient wishes to receive CPR in the event of cardiac or respiratory arrest. Options usually include "Attempt Resuscitation" or "Do Not Attempt Resuscitation (DNR)."
2. Medical Interventions: This section outlines the level of medical intervention the patient desires, ranging from full treatment (including intensive care) to selective treatment (which may include hospitalization but avoids intensive care) to comfort-focused treatment (prioritizing pain relief and symptom management over curative measures).
3. Artificially Administered Nutrition: Patients can specify their preferences regarding the use of feeding tubes or intravenous nutrition.
4. Additional Orders: Any other specific instructions or preferences the patient has regarding their medical treatment.

Differences Between POLST and Advance Directives

While POLST and advance directives both serve to document a patient's healthcare preferences, they have several key differences:

1. Scope and Specificity: Advance directives are often more general and provide an overview of a patient's wishes for future care. POLST forms are more specific and detailed, providing actionable medical orders for the patient's current health condition.
2. Medical Order Status: POLST forms are medical orders that must be followed by healthcare providers, whereas advance directives are legal documents that guide care but do not have the same immediate enforceability.
3. Target Population: POLST is intended for patients with serious illnesses or frailty, where specific instructions are necessary for immediate and near-term healthcare decisions. Advance directives can be used by anyone, regardless of their current health status.

Implementation and Use

The implementation and use of POLST forms vary by state and region, but there are common elements in their adoption and utilization:

1. Healthcare Provider Training: Proper training for healthcare providers is crucial to ensure that POLST forms are completed accurately and respected in medical settings. Training often includes understanding the legal aspects of POLST, how to discuss end-of-life care with patients and families, and the proper use of the forms.
2. Patient and Family Education: Educating patients and their families about the purpose and benefits of POLST is essential. This education helps ensure that patients make informed decisions and that their wishes are accurately documented.
3. Integration into Medical Records: POLST forms should be integrated into the patient's medical records to ensure they are accessible in all healthcare settings. Electronic health records (EHRs) can facilitate this integration, allowing for easy access and transfer of POLST information between providers.
4. Review and Update: POLST forms should be reviewed regularly and updated as necessary to reflect changes in the patient's health status or preferences. This review process ensures that the orders remain relevant and accurate.

Legal and Ethical Considerations

The use of POLST forms involves several legal and ethical considerations:

1. Legal Recognition: The legal status of POLST forms varies by state. Some states have specific legislation recognizing POLST forms as legally binding medical orders, while others may have different mechanisms for ensuring their enforceability.
2. Informed Consent: Obtaining informed consent is a fundamental ethical requirement. Patients must fully understand the implications of the choices documented in the POLST form and voluntarily agree to them.
3. Surrogate Decision-Makers: In cases where patients cannot make decisions for themselves, legally authorized representatives (such as healthcare proxies or guardians) can complete the POLST form on their behalf. It is crucial that these representatives act in accordance with the patient's known wishes and best interests.
4. Respect for Patient Autonomy: Healthcare providers must respect the decisions documented in POLST forms, even if they conflict with the provider's personal beliefs or professional judgment. Ethical guidelines and institutional policies often provide support for providers facing such conflicts.

Benefits of POLST

The POLST paradigm offers several benefits for patients, families, and healthcare providers:

1. Alignment with Patient Wishes: POLST forms ensure that medical treatment aligns with the patient's preferences, reducing the likelihood of unwanted or unnecessary interventions.
2. Clarity in Emergencies: In emergency situations, POLST forms provide clear instructions for healthcare providers, facilitating timely and appropriate care.
3. Reduced Burden on Families: By documenting their wishes in advance, patients can alleviate the decision-making burden on their families during stressful and emotional times.
4. Improved Quality of Care: POLST forms contribute to a higher quality of care by promoting patient-centered treatment and reducing the risk of medical errors.

Challenges and Limitations

Despite their benefits, POLST forms also present certain challenges and limitations:

1. Variability in Implementation: The adoption and use of POLST forms can vary widely between states and healthcare facilities, leading to inconsistencies in how they are implemented and respected.
2. Misunderstandings and Misuse: There can be misunderstandings about the purpose and scope of POLST forms, leading to misuse or inappropriate application. Ensuring proper education and training for both providers and patients is essential.
3. Evolving Patient Preferences: Patients' health conditions and preferences can change over time, necessitating regular reviews and updates of POLST forms. Failure to do so can result in outdated orders that no longer reflect the patient's wishes.
4. Complex Medical Decisions: POLST forms may not cover all possible medical scenarios, and complex decisions may still require nuanced discussions between patients, families, and providers.

The Bottom Line

Physician Orders for Life-Sustaining Treatment (POLST) are a vital tool in ensuring that patients' healthcare preferences are respected, especially in emergency situations. By providing clear, actionable medical orders, POLST forms enhance patient autonomy, improve communication between patients and providers, and contribute to higher quality and more patient-centered care. While there are challenges and limitations in their implementation, the benefits of POLST make them an important component of modern healthcare, particularly for patients with serious illnesses or frailty. Regular review and education are key to maximizing the effectiveness of POLST and ensuring that patients' wishes are honored throughout their healthcare journey.