POLST: An improvement over traditional advance directives
ABSTRACTPhysician Orders for Life-Sustaining Treatment (POLST) is a process that translates a patient’s goals for care at the end of life into medical orders that follow the patient across care settings. POLST overcomes the limitations of traditional advance directives. It enables physicians and other health care professionals, through a conversation with a patient or surrogate, to assess and convey the wishes of patients with serious life-limiting illness who may have a life expectancy of less than 1 year, or of anyone of advanced age interested in defining his or her wishes for end-of-life care.
KEY POINTS
- Failures and opportunities for improvement in current advance care planning processes highlight the need for change.
- Differences exist between traditional advance directives and actionable medical orders.
- Advance care planning discussions can be initiated by physicians as a wellness initiative for everyone 18 years of age and older and can help patients and families understand advance care planning.
- POLST is outcome-neutral and may be used either to limit medical interventions or to clarify a request for any or all medically indicated treatments.
- Shared, informed medical decision-making is an essential element of the POLST process.
POLST is expanding across the country
The use of POLST has been expanding across the United States, with POLST programs now implemented in all or part of at least 30 states. There are endorsed programs in 14 states, and programs are being developed in 26 more. Requirements for endorsement are found at www.polst.org. Figure 2 shows the status of POLST in the 50 states.
Oregon’s POLST form is the original model for other forms designed to meet specific legislative or regulatory requirements in other states. POLST-like programs are known by different names in different states: eg, New York’s Medical Orders for Life-Sustaining Treatment (MOLST) and West Virginia’s Physicians Orders for Scope of Treatment (POST), but all endorsed programs share common core elements.
POLST research
A number of studies in the past 10 years have shown that POLST improves the documentation and honoring of patient preferences, whatever they may be.4,8–16
Emergency medical technicians in Oregon reported that the POLST form provides clear instructions about patient preferences and is useful when deciding which treatments to provide. In contrast to the single-intervention focus of out-of-hospital do-not-resuscitate orders, the POLST form provides patients the opportunity to document treatment goals and preferences for interventions across a range of treatment options, thus permitting greater individualization.13
Comfort care is not sacrificed if a POLST document is in place. Most hospice patients choose at least one life-sustaining treatment on their POLST form.14
In a multistate study published in 2010, the medical records of residents in 90 randomly chosen Medicaid-eligible nursing homes were reviewed.15 POLST was compared with traditional advance care planning in terms of the effect on the presence of medical orders reflecting treatment preferences, symptom management, and use of life-sustaining treatments. The study found that residents with POLST forms had significantly more medical orders about life-sustaining treatments than residents with traditional advance directives. There were no differences between residents with or without POLST forms on symptom assessment or management measures. POLST was more effective than traditional advance planning at limiting unwanted life-sustaining treatments. The study suggests that POLST offers significant advantages over traditional advance directives in nursing facilities.15,16
In summary, more than a decade of research has shown that the POLST Paradigm Program serves as an emerging national model for implementing shared, informed medical decision-making. Furthermore, POLST more accurately conveys end-of-life care preferences for patients with advanced chronic illness and for dying patients than traditional advance directives and yields higher adherence by medical professionals.
CLINICAL CASE REVISITED
Let’s consider if the physician for our 89-year-old woman with dementia had completed a POLST form with orders indicating “do not attempt resuscitation (DNR/no CPR)” and “comfort measures only, do not transfer to hospital for life-sustaining treatment and transfer if comfort needs cannot be met in current location.”
The patient’s respiratory distress and fever would have been treated at her nursing home with medication and oxygen. She would have been transferred to the hospital only if her comfort needs would not have been met at the nursing home. Unwanted life-sustaining treatment would have been avoided. The wishes of the patient, based on her values and careful consideration of options, would have been respected.
