FINE TUNING THE POLST SYSTEM:
THE CASE OF AN INVALID, CONTRADICTORY
POLST FORM
Alvin (Woody) Moss MD, WVU Center for Health Ethics and Law*
Margaret Carley JD, RN OHSU Center for Ethics in Health Care*
Terri Schmidt MD, MS, Oregon Health & Science University (EMS)*
Paul Schneider MD, VA Medical Center, Los Angeles, CA
Kenneth Zeri RN, MS, Hospice Hawaii*
1
*National POLST Paradigm Task Force members
Current as of January 3, 2012
2
www.polst.org
A 78 year-old woman was admitted from a nursing
home with chest pain. She had a past history of
coronary artery disease status post stent placement,
congestive heart failure, hypertension, lipid
disorder, and mild dementia. A POLST form
accompanied the patient and indicated CPR in
Section A and limited additional interventions in
Section B. The attending physician wondered what
he should do with the POLST form because Section
A and Section B seemed to be contradictory. The
POLST form had been prepared by a social worker
who had signed it, but there was no physician
signature on it.
3
In transporting the patient, EMS worried, “What do I do if
she codes and I do CPR and get her back, but she is not
breathing normally? Do I intubate her?” The ED physician
wondered the same thing, but fortunately she did not suffer
a cardiac arrest.
When interviewed by the palliative care team who was
consulted to address the POLST form inconsistency, the
patient indicated that she would not want to be kept alive
on machines and when it was explained to her that if she
had CPR and lived through it, it was very likely that she
would end up being on a breathing machine. She said,
“Well then, I don’t want CPR.”
4
The patient was questioned, and she clearly
understood that without CPR in the event of a
cardiorespiratory arrest she would die. She was felt
to have decision-making capacity for her decision. A
daughter who lived out of state was the patient’s
Medical Power of Attorney representative and
wanted her mother to have CPR.
What should be done with regard to the
seemingly contradictory POLST form and the
conflict between the patient and her daughter? How
could these situations be prevented in the future?
5
Where Was the Problem in This Case?
 Can we expect POLST preparation to be any more
accurate/functional than the rest of our somewhat
inaccurate/dysfunctional system? If so, how?
Who should “own” POLST and what control
should they exert?
 In code discussions, when will providers
demonstrate the moral courage to use the word
“die”? “If God forbid you were to die during this
hospitalization, would you want us to try to bring
you back from death?”
6
Where Was the Problem in This Case?
 What was the role of the physician in this case?
The SCBCC struggled mightily over this question
and concluded physicians must at least personally
confirm the discussion when initially prepared by
a non-physician. My hospital mandates an MD
POLST discussion. VA does not allow resident,
licensed physicians to sign DNR orders > 24 hrs.
Therefore, they should not sign most POLSTs.
7
Does the patient have capacity ?
 Does the patient have capacity
 How, when and who would make this determination this in
your state?
 When can the appointed health care representatives
begin to make health care decisions?
 What happens if the patient does not have capacity
and there is no one available to make health care
decisions?
8
Can a family member override the existing
POLST Orders?
 State by state variations attributable to different
advance directives and surrogate decision maker
statutes
 May depend on if your POLST program is statutory,
regulatory or voluntary
 Outside the hospital it may depend on your out-of-
hospital DNR statute or rules
 May depend upon statutory or regulatory limitations
based on the client’s medical conditions
9
May Be Multiple Family Member Roles
 Informal roles of family members
 Primary Caregiver
 Primary Decision Maker
 Spokesperson
 Out-of-Towner
 Patient Wishes Expert
 Protector/Vulnerable Member
 Health Care Expert
 End-of-Life Decision Making in Adult ICUs: Roles & Relationships of Key
Players
 Judith Gedney Baggs, PhD, RN, FAAN
10
Minimizing or avoiding conflicts by a better
goals of care conversation
 Advance Care planning
 Goals of Care
 Communication
 What do patients and families want?
 Better communication by clinicians
 Timely, on-going, clear, complete, compassionate
 Address condition, prognosis, treatments
 Patient-focused health care decision making
 Aligned with patient values, care goals, preferences
Nelson,
Puntillo, et al. (2010), In their own words. Critical Care Medicine
11
.Was this a burdensome transition of care
from nursing home to hospital?
 “Health care transitions, such as the hospitalization of nursing home residents,
have the potential for fragmentation of care, changes in the management of
chronic diseases, duplication of diagnostic workups, and medical errors.”
 NEJM Study Results
 Among 474,829 nursing home decedents, 19.0% had at least one burdensome
transition(range, 2.1% in Alaska to 37.5% in Louisiana).
 In adjusted analyses, blacks, Hispanics, and those without an advance directive
were at increased risk.
 Nursing home residents in regions in the highest quintile of burdensome
transitions (as compared with those in the lowest quintile) were significantly
more likely to have a feeding tube, have spent time in an ICU in the last month
of life have a stage IV decubitus ulcer , or have had a late enrollment in
hospice.
Gozalo P, Teno JM, Mitchell SL, et al. End-of-Life Transitions among Nursing Home
Residents with Cognitive Issues. N Engl J Med 2011;365:1212-21.
12
EMS
 Conflicting Section A and B orders
 Section A DNR
 Section A Resus
 Section A Resus
Section B Full Treatment
Section B Comfort Measures
Section B Limited Interventions
 What should EMS do?
13
What is the trump card?
 POLST form
 Patient choice
 Family/surrogate choice (Does it matter if it is a
legal guardian? Power of attorney for health care?)
14
Hospice Care
 Staff must know basic laws governing POLST in
state
 Hospice care across most settings
 Home, SNF, Hospital, Care Home, Hospice Facility,
Homeless
 POLST “Form” may be voluntary for healthcare
institutions to use, but POLST “Orders” may be
mandatory to follow
 Legal requirements for correct document
15
Hospice Care
 Home based care
 Clarifying goals for care
 Including family
 Policies regarding completing forms
 Nursing Facility / Hospice Collaboration
 Support Facility staff in review & clarification of
POLST
 Hospice team (MD, RN, MSW) support resolution of
conflict
 Policies governing use of form
 POLST is voluntary
16
REGIONAL LUNCH
DISCUSSIONS
17
Regions
 California – Aviary Ballroom
 Midwest – Beach South
 IL, IA, MN, NE, MO, MI, OH, WI
 Northeast – Beach South
 DE, ME, NH, NJ, NY, PA, RI, DC
 South – Beach South
 FL, GA, KY, LA, NC, TN, TX, VA, WV
 West – Beach South
 CO, HI, ID, MT, NM, OR, UT, WA
18