Practitioner Orders for Life Sustaining
Treatment
Effective July 1, 2013
What is POLST?
• Practitioner Orders for Life Sustaining Treatments
• Was signed into law December 2011 and facilities
must be in compliance with POLST by July 1, 2013.
• Single page order form
• Addresses life-sustaining treatments
– Scope of care
– Option to return to hospital
– Artificial nutrition
– Code status
• Will replace the New Jersey
– “Out of Hospital DNR Form”
Where did POLST come from???

POLST began in Oregon in 1991.

Developed initially for nursing home residents who
were often transferred back and forth between the
hospital, nursing home or their home.

Expanded to more than half of US.

Studies have shown that POLST is effective in
providing care that is consistent with patient
wishes.
•
Tolle SW, Tilden VT, Nelson CA, Dunn PM: A prospective study of the efficacy of the PO(L)ST: Physician Order Form for Life-Sustaining
Treatment. J.Am Geriatr Soc 1998;46:1097-1102.
Who is the POLST for?
• Recommended for people entering their final years of
life, regardless of age
• For those diagnosed with advanced illness or frailty
– A practitioner would not be surprised if this person died
within the year
• For those who want to better define and make clear
their preferences of care
Who completes the POLST?
• In the State of New Jersey,
The Patient or Surrogate and
– Physician or
– Advanced practice nurse
– NOT
•
•
•
•
Lawyer
Social Worker
Nurse
Other members of the team
Who signs the orders and consent?
In the State of New Jersey:
• Signs the orders:
– Physician
– Advance Practice Nurse
• Signs the consent:
– Patient
– Surrogate Decision Maker
Core elements of POLST
•
•
•
•
Actionable medical orders
Complements Advance Directives
Brightly colored format > green
Hospice
care
Portable across all health care
settings
• It’s the law!
Hospital
Home
care
Nursing
facility
Office
Differences between
POLST and Advance Directive (AD)
POLST
AD
Who completes the form
Physician or Advance
Practice nurse
Patient, often with a lawyer
Time frame
Current care
Future care
Who
The seriously ill
All adults
Portability
Person and Provider
responsibility
Patient and family
responsibility
Periodic review of form
Provider responsibility
Patient and family
responsibility
Health care agent/
surrogate role
Able to engage in
Cannot complete
discussion to compose form
with physician if patient
lacks capacity.
Emergency Situation
Medical order that must be
honored, starting with
EMT’s
Cannot be interpreted or
followed by healthcare
professionals in an
emergency situation.
Core elements of POLST
• Must ask of existence and honor the most recent
POLST
• Copy the original POLST and place on chart
• Original POLST form return to patient on discharge
• To void a POLST, draw a line through all sections,
write “VOID” in large letters, and sign and date
• Meridian Health will be building POLST into
computerized documentation systems
Steps for a Physician or Advance Practice Nurse
to Complete POLST
• Having the ‘end-of-life’ discussion:
1. Check for understanding of condition
2. Share information about prognosis
3. Establish goals of care
4. Complete form and recommend treatment
FRONT
BACK
Section A - Goals of Care
• What are the specific goals that we are trying to achieve
by this treatment plan of care? This can be determined by
asking the simple question:
• “What are your hopes for the future?” Examples include
but not restricted to:
– Longevity, cure, remission
– Better quality of life
– Live long enough to attend a family event (wedding,
birthday, graduation)
– Live without pain, nausea, shortness of breath
– Eating, driving, gardening, enjoying grandchildren
• Medical providers are encouraged to share information regarding
prognosis in order for the person to set realistic goals.
Section B – Medical Interventions
[] Full treatment
[] Limited treatment
– When "limited treatment” is selected, also indicate if the
person [] prefers or [] does not prefer to be transferred
to a hospital for additional care.
[] Symptom treatment only – examples:
– IV medication to enhance comfort may be appropriate
for a person who has chosen “symptom treatment
only.”
– Non-invasive positive airway pressure includes
continuous positive airway pressure (CPAP), or bi-level
positive airway pressure (BiPAP).
Comfort measures will always be provided.
Section C – Artificially Administered Fluids and
Nutrition
Always offer food/fluids by mouth if feasible and desired.
[] No artificial nutrition
[] Defined trial period of artificial nutrition
[] Long-term artificial nutrition
• Oral fluids and nutrition should always be offered if
medically feasible and if they meet the goals of care
determined by the person or surrogate.
• The administration of nutrition and hydration whether
orally or by invasive means shall be within the context
of the person’s wishes, religion and cultural beliefs.
Section D – Cardiopulmonary Resuscitation and
Airway Management
• CPR:
Person has no pulse and/or is not breathing
[]Attempt resuscitation/CPR
[]Do not attempt resuscitation/DNAR
Allow Natural Death
• AIRWAY MANAGEMENT
Person is in respiratory distress with a pulse
[]Intubate/use artificial ventilation as needed
[]Do not intubate - Use O2, manual treatment to relieve
obstruction, medications for comfort
Section E – Decision Making Capacity
• If I lose my decision-making capacity, I authorize my
surrogate decision maker, listed below, to modify or
revoke the NJ POLST orders in consultation with my
treating physician/APN. [] Yes [] No
• Print name of Surrogate/Phone number
• NOTE: This section is applicable in situations where
the person has decision making capacity when the
POLST form is completed.
• A surrogate may ONLY void or modify an existing
POLST form, or execute a new one, if named in this
section by the person.
Section F - Signatures
• I have discussed this information with my
physician/APN.
• Signature___________________________________
[]Person Named Above
[]Health Care Representative/Legal Guardian
[]Spouse/Civil Union Partner
[]Parent of Minor
[]Other Surrogate____________________________
Section F continued
• Anatomical Gift – has person named above made an
anatomical gift:
[]yes []no []unknown
• These orders are consistent with the person’s medical
condition, known preferences and best known
information.
• PRINT: Physician/APN Name, Phone Number
Physician/APN Signature: (Mandatory) Date/Time
POLST in Summary
Practitioner Orders for Life Sustaining Treatments
• Actionable medical orders that must be honored
at point of contact with by EMS, ED, hospital, etc.
• Portable across all settings.
• Does not require a loss of decision-making
capacity for it to go into effect.
• Legally sufficient and recognized as a medical
order.
• POLST forms are green, to promote
recognizability.
Meridian Health: For emergency room patients
(on all initial assessments)
•
•
•
•
•
•
Inquire about the existence of a POLST form.
Make physician in charge of the patient at the time aware of the existence of a POLST
form, as they will need to review it and determine if any new orders are indicated. In
notifying the physician about the existence of the POLST, discuss the orders contained
within it.
Document the existence of the POLST and your communication of it to the physician or
LIP (Licensed Independent Practitioner)
Honor the POLST unless new medical orders dictate otherwise. Make a copy of the
POLST (both sides) and place in the medical record orders section. Place a patient
identifying label on the copy document and write COPY on the copied form with the date
copied. Keep the original POLST in the medical records section as well, returning that
original to the patient upon their discharge.
Physicians/LIPs are expected to document the reasons for deviation from the POLST in
the medical record after discussing the changes with the patient.
In all communication handoffs, especially if the patient is admitted, communicate the
existence of the POLST form.
Meridian Health: For admitted patients
(on all initial assessments)
•
•
•
•
•
•
•
•
•
Make physician in charge of the patient at the time aware of the existence of a POLST form, as they
will need to review it and determine if any new orders are indicated. In notifying the physician about
the existence of the POLST, discuss the orders contained within it.
Document the existence of POLST and your communication of it to the attending physician or LIP
The POLST form (legally actionable medical orders) is in effect until the physician/LIP is able to
reassess the patient more fully and determine with the patient if any changes to the document are
necessary.
In the absence of any other orders, POLST provisions for care, including DNR, are in effect.
Make a copy of the POLST (both sides) and place in the medical record orders section. Place a
patient identifying label on the copy document and write COPY on the copied form with the date
copied. Keep the original POLST in the medical records section as well, returning that original to the
patient upon their discharge.
Upon physician/LIP review and assessment, any hospital required forms, such as DNR orders, will
be completed to complement POLST intentions.
Upon discharge, if the POLST has been updated, send the most current original with the patient
during any transfers or discharge to home. The physician/LIP should void the old POLST, by
drawing a line through sections A through D and writing VOID in large letters on it.
Document that the POLST form accompanied the patient on discharge/transfer.
In all communication handoffs, especially to the EMS personnel on discharge, communicate the
existence of the POLST.
POLST questions
1.
2.
The POLST is a legal document. True False
The POLST form includes:
a. Goals of treatment
b. Preferences related to CPR, intubation and mechanical
respiration
c. Preferences for artificial nutrition and hydration
d. All of the above
3. The POLST is transferable across all settings. True False
4. The Nurse must copy the POLST and make physician in charge of
the patient at that time, aware of the existence of a POLST form.
True False
5. POLST should be initiated by Physician or Advanced Practice Nurse
when the person is diagnosed with advanced disease or frailty. True
False