Thursday, May 24, 2012

A Chance to Revise the POLST


We have written a lot about POLST (Physician Orders for Life Sustaining Treatment) in previous GeriPal posts. Mostly, with great admiration for the entire program and for the amazing efforts of partnerships like the Coalition for Compassionate Care of California.  But, just like every in life, even the best programs can always be made better.  With that in mind, the Documentation Committee of the POLST Task Force is now considering suggestions and recommendations for changes to the form.

Submissions are due June 15th, 2012, and importantly, these submissions should provide significant or substantial improvement or clarification to the form.   With that said, I'd first like to encourage all of you to submit recommendations if you have them.  Secondly, I'd also like some feedback on two of the recommendations that we are considering submitting.  Both come from previous posts (see here and here) and mainly revolve around avoiding value-laden phrases that we think add little to no value.

Recommendation #1: Change the title to POST (Physician Orders for Scope of Treatment)

Lets face it, for many of the interventions proposed on the POLST, it is a little bit of a stretch to say that they would actually sustain life in the population POLST targets. Take CPR in a frail patient with an advanced disease. Sustaining life is actually the much less common outcome of CPR than death. Furthermore, as Helen Kao wrote in a previous post:
making selections on a document labeled “Life-Sustaining Treatments” implies that you are making a choice between Life and the opposite of life — aka death — and that the Treatments listed must, of course, successfully sustain your life (or why would you label the document “Life-Sustaining Treatments”)?

What could be alternative titles? Well that is a question that I'd like to get some feedback from our audience before we submit our recommendations.  My first thought was "Potentially Life-Sustaining Treatments" although something still feels a little lacking with this term.  Dr. Kao recommended examples from other states including "Physician Orders for Scope of Treatment" or "Medical Orders for Scope of Treatment".  The nice thing about scope of treatment is that it simply tells the "readers, caregivers, providers, what types and levels of care an individual wants" and removes the "implication that using a POLST form means choosing death over life."

Recommendation #2: Remove the words "Only" and “Full Treatment” from the Medical Interventions section

Comfort Measures Only versus Full Treatment?  Really, is this a choice?  This is akin to asking "do you want everything?"  Of course I do, and that pretty damn well include expert symptom management hopefully from an interdisciplinary hospice or palliative care team.  And why "only" before comfort measures? This is the type of wording that makes one feel that it is somehow a lesser alternative, further promoting the idea that when people choose not to die in the ICU on a ventilator they have in some ways "given up" their fight with their disease.

So what is the fix? Well, as mentioned previously, it would be helpful if we just stopped adding value laden terms to important end-of-life documents. Currently, the California POLST has this as one option:
[] Full Treatment: Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care. 
What if it just said:
[] Includes all care described above. In addition, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.

Which do you like better? Did the addition of the phrase “Full Treatment” add any more information that wasn't there in the revision?  For me it's no, but I'm just one person.  What do you think?

Final Note: How to Submit Your Own Recommendations

All suggestions may be submitted via e-mail to Erin Henke, ehenke@coalitionccc.org, by June 15, 2012.  Submissions should comply with the following format:
  • Name of person/organization submitting suggestion 
  • Section of the POLST Form affected (Section A, B, C, D, Introductory paragraph, Directions for Health Care Providers, etc.) 
  • Specific revision being requested
  • Rationale for the change, or description of the issue the revision will address

Also, per the announcement, a guiding principle in the review process is that any change must provide significant or substantial improvement or clarification to the form. Two additional considerations are to (1) maintain the CA POLST form as a one-page, two-sided document, and (2) keep all the critical information on the front of the form for ease of reference.


by: Eric Widera (@ewidera)

4 comments:

Judy Citko said...

Eric

Thanks for spreading the word about the solicitation of comments on the POLST form.

For readers interested in changing the title of the form, please note that this change goes beyond the form itself. It encompasses state statue. So this change requires legislation, it cannot be accomplished through revision of the form.

Judy Citko, JD
Executive Director
Coalition for Compassionate Care of CA

Sound Health P4 Medicine said...

What has always surprised me is that if 911 is called (at least in Seattle), this means that you want EVERYTHING that the Medic-Cowboys have on their rig despite a POLST with limited interventions.

Eric Widera said...

Judy,

Thanks for the information. Looks like we may need to rethink recommendation #1.

Also, thanks for leading the way with the POLST. I have always been so very impressed by your organizations dedication to respecting individuals preferences at the end of life.

Eric Widera said...
This comment has been removed by the author.