POLST Programs: When Advance Directives Aren't Enough

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Preparing for end-of-life decisions is a difficult, yet important, task that many people either are not aware of needing to do, or wish to avoid thinking about. However, caregivers and patients alike should be informed, realistic and proactive when trying to plan for the uncertain future.

Various steps such as drafting an advance directive or living will, completing the appropriate HIPPA authorization form, and preparing a health care proxy document ensure that each person's unique wishes and best interests are protected later in life. But did you know that some states have an additional program in place to safeguard the medical decisions of those who are seriously ill, called a POLST?

What is POLST?

The Physician Orders for Life-Saving Treatment (POLST) Program is a method of end-of-life planning specifically intended for individuals who are extremely frail, or who have life-limiting or terminal illnesses. Through a series of in-depth conversations, patients collaborate with loved ones and physicians in order to discuss their health issues and outline their current wishes for end-of-life care.

The resulting POLST form is unique in that it is signed by a medical professional, functions explicitly as a medical order and is meant to accompany patients as they transition through different care settings (e.g. home, hospital, nursing home, etc.). Even emergency medical personnel such as EMTs and paramedics are required to abide by the instructions stipulating which life-saving treatments are to be used or avoided. This is in contrast to advance care directives, which are often not completed with the help of a health care professional, and may or may not be capable of guiding emergency medical personnel. If emergency responders can't access an unconscious elder's advance directives, then their default is to provide any and all life-saving treatment. Even when a person's advance directives can be located, studies have shown that these forms are easily misinterpreted, causing patients to receive unwanted care.

The specifics of POLST forms vary by state, but patients can typically decide to be given comfort measures only, receive limited interventions that can be tailored to meet specific wishes (i.e. antibiotics, IV fluids and cardiac monitoring, but not intubation or mechanical ventilation) or full treatment, in the event of a medical crisis.

In the case of changes of heart, changes in health or transfers between medical institutions, POLST forms may also be voided or altered at any time by patients with decision-making capabilities or by appropriately appointed surrogates who have consulted with the treating physician.

Proving the benefits of POLST

To help test the effectiveness of POLST forms in helping terminally ill patients receive the medical care they desire, the Journal of the American Geriatrics Society (JAGS) recently published a study of severely-ill patients in Oregon, which examined the relationship between their medical stipulations on POLST forms and where they died.

The study utilized death records of 58,000 Oregonians, of which approximately 30 percent had POLST forms filed with the state's registry. Researchers then checked the association between the medical orders specified on the forms and the location in which the individuals died.

Results showed that patients who expressed their desires for end-of-life care through POLST forms had their wishes honored, more often than not. Fewer than seven percent of individuals who specified comfort measures only on their forms died in a hospital, compared to 22.4 percent who chose limited additional measures and 44.2percent of those that requested full treatment.

POLST movement gaining ground

While advance directives are easily accessible, regardless of where an individual lives, POLST Programs are not yet available nationwide. The National POLST Paradigm Task Force has reviewed and endorsed programs in a number of states, but many others are still in various stages of planning and development. The program name can differ by state and variations include POST, MOST, MOLST, and TPOPP.

Currently, the National POLST Paradigm only acknowledges Oregon and West Virginia as having "mature" POLST Programs that are the standard, statewide method of end-of-life planning for those who are significantly weak or ill. If you think that POLST may be helpful for you or someone you care for, a quick check on the National POLST Paradigm website will tell you if there is a program in your state or region.

POLST forms address only a few medical preferences for end-of-life care such as the administration of CPR, antibiotics, and artificial feeding and hydration. These medical orders are meant to complement (not replace) advance directives, which provide broader treatment guidelines. If your loved one has already drafted a living will or advance directive, be sure to bring a copy for your physician when filling out a POLST form to ensure that the two do not conflict.

Keep in mind that, while engaging in end-of-life planning, you and your loved one will be sorting through delicate and complex decisions. The legal and medical paperwork may be daunting, but it is of utmost importance that the documents you have on file are accurate, up to date and do not conflict with one another.

Discover how one veteran caregiver suggests approaching conversations with elders about end of life issues.

Ashley Huntsberry-Lett

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Ashley is responsible for the planning and creation of AgingCare.com’s award-winning content. As a teenager, she assisted in caring for her step-father during his three-year battle with colon cancer. Now, through her work at AgingCare.com, she strives to inform and empower the caregivers who devote so much to helping and healing the ones they love.

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2 Comments

This is helpful however, my problem does not involve the problem of not having had such discussion with my Mom. It was made very, very clear as to what she wanted and it is certainly not to live in the condition she is now (severe dementia). Her HCP indicates clearly that she did not want resuscitation or anti-biotic. I have been forced to give it to her 3 times over the past 2 years against my verbal instruction and had a DNR ignored once. Doctors, ERs and nursing homes need to be made more aware of what patients and guardians wishes are and respect those decisions. The "easy fix" the Drs. call anti-biotics doesn't fix the dementia and its effects. Those of us who are the Proxy agents need to stand strong against the money sucking systems in place and Doctors that say you can't do something that is so clearly written. If anything I have learned is to call for a patient advocate before you let them do anything against your loved ones wishes. Here I am living with the guilt of what her life has become over the last year and half.
Patient Advocate is a great idea! Mthr wants nothing to prolong if she is terminal w 6 mos or fewer. Her doc won't sign PLOST until then, even though she is in late stage 6. I want to spare her from having CPR and breaking bunches of ribs just for her to survive the night before expiring, as I hear so many elderly folks do. I can't bear the thought. I plan to laminate the pink copy and frame it over her bed!