Monday, April 19, 2010

POLST: Standardizing End-of-Life Orders rather than Patient Communication

Over the last 30 years we have tried to standardize patient communication about end-of-life issues though the utilization of statutory advance health care directive forms. While this approach has not been a complete failure, the results have been less than stunning given the amount of resources allocated to this endeavor. Is there a better way? At the Coalition for Compassionate Care of California (CCCC) Annual Meeting, Charles Sabatino, JD, talked about one possibility – the POLST paradigm.

Mr. Sabatino is the Assistant Director of the American Bar Association’s Commission on Law and Aging, as well as a professor at Georgetown University Law Center. At today’s CCCC meeting, Mr. Sabatino gave a presentation on the inadequacy of a legal transactional approach that has dominated advance care planning, best exemplified by the Advance Directive document. He describes how the transactional approach is beginning to give way to “communication approach” to advance care planning, where shared decisions are made between patients, families, and healthcare providers on a ongoing basis. The communication approach requires healthcare providers to learn about the goals and values held by their patients, which is then converted into a portable plan of care: the POLST.

The POLST paradigm does not attempt to standardize patient communication about preferences at the end-of-life. The Advance Directive still attempts to accomplish this, although as it is a complex and highly individualized process, standardization becomes difficult. Rather, as Mr. Sabatino points out, POLST attempts to standardize physician end-of-life orders for patients with serious illnesses. The goal is to translate the complex discussions around the values of patients into specific medical orders. The standardized forms include orders addressing:
  • Cardiopulmonary resuscitation
  • Administration of antibiotics and IV fluids
  • Use of intubation and mechanical ventilation
  • Use of artificial nutrition

Twelve states have adopted the POLST paradigm into law (CA, HI, ID, MD, NY, NC, OR, TN, UT, WA, WV), and many more are developing programs. My state (California) has signed the POLST into law, although implementation in San Francisco is spotty at best.

I’m interested in hearing from the GeriPal community what they think about the POLST. Have you used it? What are your concerns with it? What do you think are the strengths and weaknesses? Please comment and discuss!

4 comments:

David Tribble said...

In Tennessee, we have the POST (Physician's Orders for Scope of Treatment) which looks for all the world like the POLST used everywhere else. When people remember to carry it during transport and to show it to ambulance personnel when there has been a 911 call, it works pretty well.

I agree that it uses a more transactional approach and that it steps away from Code or No Code as an all-or-nothing-at-all phenomenon.

In our state, the specific value of the POST is that it crosses all venues as well as transport in between, and we are fanatical about making sure we have a completed form for any patient who is being transported anywhere.

There are those who would like to use the form in lieu of conversation, which, of course, is not the intent. The form is a standard way to document the conversation.

In general, however, it has proved useful.

David Tribble, MD
Chief Medical Officer
Alive Hospice, Inc.
Nashville, TN

Steve Lai said...

In Santa Clara County, we have been leading the efforts to educate and make POLST a community-wide practice since late 2007. Our primary focus was to improve the advance care planning process during the transition of care, especially between hospital and skilled nursing facilities. From our experience, the POLST is not just a form, but a great opportunity to highlight the importance of having rich, meaningful discussions with patients and families incorporating a patient's values and goals into treatment preferences. The greatest challenge has been implementation at SNF's where it is often treated like another "form" that just needs to be signed by the physician. For successful implementation, it does take buy-in from the SNF leadership and sustained educational efforts for the interdisciplinary team (social workers, nurses) to acquire and use skills in starting these important conversations.

Lynn said...

We starting using it at our SNF about six months ago. It works really well for transfers when people use it properly.

I have noted the following practical issues:

-Our POLST forms always go with patients to the hospital, but they never come back with them. Lesson: send a copy. Copies and faxes are valid.

-Patients who initially say they would like a trial of life-sustaining therapies in the event of cardiac or respiratory arrest do not need a POLST form, as full code is the default. However, since SNFs are so very protocol/paperwork-driven, there is pressure to fill out POLSTs even for these patients. I don't always want them to sign on the dotted line for full code. It makes it seem so "official" and might make it more difficult to change things in the future.

-At the end of a goals of care discussion, I used to gently ask permission to document the patient's wishes in the chart. Now I have to ask them to physically sign a bright pink form. Kind of jarring for the patient and/or family.

-The form is NOT a good substitute for documenting treatment limitations within the SNF setting. It's best for EMS workers. This is why it is laid our like the ACLS protocol.

All of this said, I think it is much more effective than the standard living will found within many advance directives.

LindaB said...

As I sat with a lovely and aged woman and her family this afternoon, reviewing the POLST, I was struck by how useful the form is for facilitating a difficult conversation, especially with families that have historically had a great deal of tension about many things, including life sustaining treatments.

The family in question had a lot of baggage about the appropriate care for the patient-- including food, nutriceuticals, medications, money to name a few. It was nice to see them, come together to design an appropriate plan for a person who is severely impaired. The form gave us a focus to build the conversation around. Now to ensure that the nursing home physician honors the plan and the intention.