POLST: An improvement over traditional advance directives

The importance of a health care proxy (durable power of attorney for health care)

In a health care proxy document (also known as durable power of attorney for health care), the patient names a health care agent. This person has authority to make decisions about the patient’s medical care, including life-sustaining treatment. In other words, you the patient appoint someone to speak for you in the event you are unable to make your own medical decisions (not only at the end of life).

Since anyone may face a sudden and unexpected acute illness or injury with the risk of becoming incapacitated and unable to make medical decisions, everyone age 18 and older should be encouraged to complete a health care proxy document and to engage in advance care planning discussions with family and loved ones. Physicians can initiate this process as a wellness initiative and can help patients and families understand advance care planning. In all health care settings, trained and qualified health care professionals can provide education on advance care planning to patients, families, and loved ones.

A key issue when naming a health care agent is choosing the right one, someone who will make decisions in accordance with the person’s current values and beliefs and who can separate his or her personal values from the patient’s values. Another key issue: people need to have proactive discussions about their personal values, beliefs, and goals of care, which many are reluctant to do, and the health care agent must be willing to talk about sensitive issues ahead of time. Even when a health care agent is available in an emergency, emergency medical services personnel cannot follow directions from a health care agent. Most importantly, a health care agent must be able to handle potential conflicts between family and providers.

POLST ENSURES PATIENT PREFERENCES ARE HONORED AT THE END OF LIFE

Approximately 20 years ago, a team of health care professionals at the University of Oregon recognized these problems and realized that physicians needed to be more involved in discussions with patients about end-of-life care and in translating the patient’s preferences and values into concrete medical orders. The result was the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program.⁴

What is POLST?

POLST is an end-of-life-care transitions program that focuses on patient-centered goals for care and shared informed medical decision-making.^5,6 It offers a mechanism to communicate the wishes of seriously ill patients to have or to limit medical treatment as they move from one care setting to another. Table 1 lists the differences between traditional advance directives and POLST.

Reprinted with permission of the Center for Ethics in Health Care, Oregon Health & Science University.

The aim is to improve the quality of care that seriously ill patients receive at the end of life. POLST is based on effective communication of the patient’s wishes, with actionable medical orders documented on a brightly colored form (www.ohsu.edu/polst/programs/sample-forms.htm; Figure 1) and a promise by health care professionals to honor these wishes.⁷ Key features of the program include education, training, and a quality-improvement process.

Who is POLST for?

POLST is for patients with serious life-limiting illness who have a life expectancy of less than 1 year, or anyone of advanced age interested in defining their end-of-life care wishes. Qualified and trained health care professionals (physicians, physician’s assistants, nurse practitioners, and social workers) participate in discussions leading to the completion of a POLST form in all settings, particularly along the long-term care continuum and for home hospice.

The key element of the POLST process: Shared, informed medical decision-making

Health care professionals working as an interdisciplinary team play a key role in educating patients and their families about advance care planning and shared, informed medical decision-making, as well as in resolving conflict. To be effective, shared medical decision-making must be well-informed. The decision-maker (patient, health care agent, or surrogate) must weigh the following questions (Table 2):

• Will treatment make a difference?
• Do the burdens of treatment outweigh its benefits?
• Is there hope of recovery? If so, what will life be like afterward?
• What does the patient value? What is the patient’s goal for his or her care?

In-depth discussions with patients, family members, and surrogates are needed, and these people are often reluctant to ask these questions and afraid to discuss the dying process. Even if they are informed of their diagnosis and prognosis, they may not know what they mean in terms of their everyday experience and future.

Health care professionals engaging in these conversations can use the eight-step POLST protocol (Table 3) to elicit their preferences at the end of life. Table 4 lists tools and resources to enhance the understanding of advance care planning and POLST.

What does the POLST form cover?

The POLST form (Figure 1) provides instructions about resuscitation if the patient has no pulse and is not breathing. Additionally, the medical orders indicate decisions about the level of medical intervention that the patient wants or does not want, eg, intubation, mechanical ventilation, transport to the hospital, intensive care, artificial nutrition and hydration, and antibiotics.

Thus, POLST is outcome-neutral and can be used either to limit medical interventions or to clarify a request for any or all medically indicated treatments.

Both the practitioner and the patient or patient’s surrogate sign the form. The original goes into the patient’s chart, and a copy should accompany the patient if he or she is transferred or discharged. Additionally, if the state has a POLST registry, the POLST information should be entered into the registry.