PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2015 COUNCIL MEETING. RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
36(15)
SUBMITTED BY:
Colorado Chapter
Florida College of Emergency Physicians
New Jersey Chapter
Palliative Medicine Section
Texas College of Emergency Physicians
SUBJECT:
Establishing State and National POLST/EOL Registries
PURPOSE: Directs ACEP to partner with organizations to advocate for and support creation of state and/or a
national POLST/EOL database(s) that can be accessed by emergency physicians; create a task force charged with
promoting POLST/EOL registries; exploring cost and regulatory barriers to creating EOL databases, seeking
funding options for their creation; consider establishing a database or identifying partners to set up databases;
provide a report to the Council in 2016; continue to promote advanced care and end of life planning and
coordination as a best practice.
FISCAL IMPACT: Budgeted staff resources to explore and advocate for the development of a database.
Approximately $15,000 for a task force meeting or related expenses to promote POLST/EOL registries.
Additional expenses to retain a consultant may be required to implement the resolution, which could involve
significant expense.
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WHEREAS, The American population is rapidly aging, with an estimated 20% of the U.S. population
over the age of 65 by 2050, and many more patients living with complex serious illness; and
WHEREAS, Palliative and end of life care is an essential service provided in the ED and will become
ever more common in the everyday practice of emergency medicine as our population ages; and
WHEREAS, The patient, to the greatest extent possible, should determine the care provided to them,
especially while dying or at the end of life; and
WHEREAS, Well-recognized programs such as Physician Orders for Life-Sustaining Treatment
Paradigm (POLST) exist in some form, often under different acronyms, in 45 of the 50 states, but with great
heterogeneity in the services provided; and
WHEREAS, Medicare, as of 2016 will compensate physicians for “advanced planning,” leading to a
likely boom in the number of completed Advance Directives and POLST forms completed; and
WHEREAS, Many patients have end of life wishes documented in POLST, advance directives, or other
forms, and due to the acute nature of illness and/or lack of a coordinated medical system, these forms are often
unavailable to the Emergency Physicians treating the patient in the ED; and
WHEREAS, Emergency Physicians without a POLST form or clear next of kin decision maker are often
compelled by current practice standards and malpractice fears to provide care at the end of life that may be futile,
costly, and worst of all, against a patient’s documented end of life wishes; and
WHEREAS, A system such as the POLST Registry, available only in Oregon at this time, may help
physicians know patient wishes and decrease the incidence of futile care or care that violates a patient’s wishes;
and
Resolution 36(15) Establishing State and National POLST/ EOL Registries
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WHEREAS, POLST forms are of tremendous use to emergency physicians and providers to guide
decisions for critically ill patients, that reflect their values; and
WHEREAS, A POLST or End-of-Life Registry easily accessible to emergency physicians and medical
providers would improve clinical practice, increase certainty around care at the end of life and decrease unwanted
and costly futile care; and
WHEREAS, ACEP as an organization recognizes the need to improve palliative care in the ED, including
it as one of its Choosing Wisely goals and supporting a Palliative Medicine Section; and
WHEREAS, Multiple organizations, including but not limited to, the AMA, IOM, AAHPM, and HPNA
all advocate for improvements in patient-centered end of life care and coordination and against futile care; and
WHEREAS, Other coordinated systems such as Poison Centers and Narcotic Drug Databases,
demonstrate that centralized data hubs and knowledge bases are possible, cost efficient service to medical
providers and patients; therefore be it
RESOLVED, That ACEP partner with organizations such as the American Medical Association,
American Academy of Family Physicians, American Academy of Hospice and Palliative Medicine, Hospice and
Palliative Nurses Association, AARP, and all others it deems fit to advocate for and support the creation of state
and/or a national POLST/EOL database(s) that can be accessed by emergency physicians in times of crisis and
uncertainty around a patient’s end of life care; and be it further
RESOLVED, That ACEP create a task force charged with promoting POLST/EOL registries, explore the
cost and regulatory barriers to creating such databases, seek funding options both internally and externally for the
creation of POLST/EOL databases and considers either setting up a database or identifying partners that can set
up POLST/EOL databases for the benefit of our members and the American public; and be it further
RESOLVED, That the POLST/EOL Registries task force report back to the Council in 2016 with
actionable items that the Council, Board, and ACEP can pursue to bring about POLST and end of life databases;
and be it further
RESOLVED, That ACEP continue to promote advanced care and end of life planning and coordination as
a best practice.
Background
This resolution directs the College to partner with organizations to advocate for and support the creation of state
and/or a national Physician Orders for Life-Sustaining Treatment (POLST) and end of life (EOL) database(s) that
can be accessed by emergency physicians, to create a task force charged with promoting POLST/EOL registries,
exploring cost and regulatory barriers to creating such databases, seeking funding options for the creation of
databases, considering setting up a database or identifying partners to set up databases, reporting back to the
Council in 2016, and continue to promote advanced care and end of life planning and coordination as a best
practice.
National Quality Forum
The National Quality Forum’s (NQF) 2006 “A National Framework and Preferred Practices for Palliative and
Hospice Care Quality,” endorses 38 preferred practices as suitable for implementation by palliative care and
hospice programs. Several preferred practices address registries and healthcare and community collaboration.
Preferred Practice 34: convert patient treatment goals into medical orders and ensure that the
information is transferrable and applicable across care settings.
Resolution 36(15) Establishing State and National POLST/ EOL Registries
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Preferred Practice 35: make advanced directives and surrogacy designations across care settings while
protecting patient privacy and adherence to HIPAA regulations, for example, by using Internet-based
registries or electronic personal health records.
Preferred Practice 36: develop healthcare and community collaborations to promote advance care
planning and the completion of advance directives for all individuals, for example, the Respecting
Choices and Community Conversations on Compassionate Care programs.
Registries
Several states have end-of-life registry programs, including Louisiana; Montana (stores in secure computer
database and makes documents available to providers; Montana code authorizes attorneys general to create and
maintain end-of-life registry); and West Virginia (eDirectives Registry available to providers).
POLST registries have been implemented in Oregon and a bill is being considered in California. Idaho has a
healthcare directive registry and New York has an eMOLST (medical orders for life sustaining treatment)
registry.
Organizations such as the US Living Will Registry (makes people’s healthcare choices available to their
caregivers and families whenever and wherever they are needed while maintaining confidentiality) and
Compassion and Choices provide information on each state’s advance directive registry.
Resources such as “Electronic Registry Development” from the West Virginia eDirectives Registry and the
Archstone Foundation and the Retirement Research Foundation’s “Pathways to POLST Registry Development:
Lessons Learned,” provide guidance on establishing POLST registries.
ACEP’s End of Life Task Force Recommendations
An End of Life Task Force was appointed in 2015 with two primary objectives: 1) catalog existing resources
available through ACEP; and 2) make recommendations of additional programs and resources that ACEP could
develop. One of the task force’s recommendations is to survey chapters on end of life issues and resources
available in each state.
ACEP Strategic Plan Reference
Goal 1 – Reform and Improve the Delivery System for Emergency Care
Objective A – Develop and promote delivery models that provide effective and efficient emergency medical care
in different environments. Tactics include:
- Develop initiatives and explore partnerships with other healthcare organizations and physicians and
policy groups to support improved education for physicians, patients and their families regarding end-oflife decisions.
- Engage chapters and other medical organizations to promote Physician Orders for Life Sustaining
Treatment (POLST) and other effective advance directive documents.
Fiscal Impact
Budgeted staff resources to explore and advocate for the development of a database. Approximately $15,000 for a
task force meeting or related expenses to promote POLST/EOL registries. Additional expenses to retain a
consultant may be required to implement the resolution, which could involve significant expense.
Prior Council Action
Amended Resolution 21(13) End-of-life Care Public Hearings adopted. Directed ACEP to work with other
relevant stakeholders to engage in a national conversation and make recommendations on end-of-life issues.
Amended Resolution 31(11) End of Life Care adopted. Directed ACEP to study how emergency medicine can
positively affect end of life care, specifically addressing the provision of compassionate and dignified end of life
care, and the necessary stewardship of resources; work with other appropriate entities to address patient focused,
Resolution 36(15) Establishing State and National POLST/ EOL Registries
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compassionate end of life care; and update the membership regarding actions being taken by ACEP on the
important topic of end of life care.
Prior Board Action
June 2015, reviewed recommendations from the End of Life Task Force regarding current end of life initiatives
and resources and discussed additional resources ACEP could develop.
Resolution 21(13) End-of-life Care Public Hearings adopted.
Resolution 31(11) End-of-life Care adopted.
Background Information Prepared by: Marjorie Geist, RN, PhD, CAE
Academic Affairs Director
Reviewed By: Kevin Klauer, DO, EJD, FACEP, Speaker
James Cusick, MD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director