Physician Orders for Life Sustaining Treatment (POLST):
Past, Present and Future
POLST: Past, Present and Future
Answering Your Questions About Illinois’
POLST Program
April 9, 2014
Supporting National Healthcare Decisions Day, April 16
Julie Goldstein, MD
polstil.org
Conflict of Interest
• Dr. Goldstein is receiving no monetary
reimbursement for this presentation.
• Apart from her role as chair of the POLST Illinois
Taskforce, Dr. Goldstein is also certified State Faculty
for the Respecting Choices® Physician Orders for
Life-Sustaining Treatment Paradigm Program.
• Respecting Choices® is one of many programs
available for POLST training and is not specifically
endorsed by the POLST Illinois Taskforce.
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Disclaimer
• The legislation that covers the use of the IDPH
Uniform DNR Advance Directive/POLST form in
Illinois does not provide guidance in all areas.
• The views expressed during this webinar represent
the POLST Illinois Taskforce’s current assessment
based on available information.
• Dr. Goldstein is not providing legal or medical advice.
Please consult your institution’s legal counsel when
appropriate.
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Agenda
• Brief overview and history of POLST – for more detailed
information visit www.polstil.org
• Participant polls conducted throughout the webinar to
help us gauge level of use and understanding
• Review commonly asked questions (top 20 with
answers are posted on website)
• Participant questions
• Follow up slides incorporating additional questions
from the call will be made available
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Background
• In March, 2013 Illinois modified the “IDPH
Uniform DNR Advance Directive” to bring it closer
to the National POLST paradigm standards used
in other states.
• In this presentation, “POLST” is being used to
refer to the form as shorthand.
• POLST stands for “Physician Orders for LifeSustaining Treatment”.
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POLST Use in the United States
Mature Program
Endorsed Program
Developing Program
No Program
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Benefits of IDPH DNR/POLST in Illinois
• Promotes patient-centered quality care
• Concrete medical orders that must be followed
by healthcare providers
• Follows patient from care setting to care setting
• Reduces medical errors by improving guidance
during life-threatening emergencies
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POLST is NOT for everyone!
The POLST program is designed for:
 Patients facing life-threatening complications,
regardless of age; and/or
 Patients with advanced frailty and limited life
expectancy; and/or
 Patients who may lose the capacity to make their
own health care decisions in the next year (such as
persons with dementia); and/or
 Persons with strong preferences about current or
anticipated end-of-life care.
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Advance Care Planning IS for Everyone!
ACP Life Cycle
FIRST PHASE:
Complete a PoA. Think
about wishes if faced with
catastrophic neurological
injury.
NEXT PHASE:
Consider if, or how, goals
of care would change if
interventions resulted in
bad outcomes or severe
complications.
LAST PHASE:
End-of-Life planning establish a specific plan of
care using POLST to guide
emergency medical
orders based on goals.
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Promoting Patient-Centered Care
POLST promotes quality care through informed end-of-life
conversations and shared decision-making:
• Improve conversations, then translate wishes into
actionable medical orders
• Encourage quality conversations by skilled persons with
proper training (as determined by institution)
• A process, not a single conversation
• Allows the patient more time to think about future
scenarios and discuss them with family, friends and care
providers
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POLL:
Is Your Organization Completing
POLST forms with Patients?
Answers:
Frequently
Occasionally
Never
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The IDPH DNR/POLST Form in Illinois
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The POLST Form
Comfort care for all patients at all times!
3 Primary Medical Order Sections:
A. CPR for Full Arrest, Yes or No
• CPR/DNR applies to persons who have died (unconscious, no heart beat, not breathing)
• DNR does not imply the person wishes to limit treatment when still alive
B. Orders for Pre-Arrest Emergency
• Treatment for patients who are having emergency deterioration but are not dead
• Level of care treatment plans, which can be thought of as “Strictly Comfort Care”,
“Limited but Noninvasive Medical Interventions”, or “Full Treatment with all
Medically Indicated Treatments”
C. Artificial Nutrition
• Acceptable, Trial or Never
13
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Proposed Legislation:
SB 3076 and HB ?
Proposed Changes:
• P in POLST would stand for “Practitioner”; expands who may
execute the POLST form to include advanced practice nurses,
physician assistants and some medical residents.
• Removes “Advance Directive” from title; form complements
advance directives as a translational tool, addresses specific
medical circumstances with the actionability of a medical
order.
• Adds “POLST” to “DNR” in formal title; patients may use form
to request CPR rather than to request DNR.
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Questions…
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Q: Are we required to follow the
orders on the POLST form?
A:
YES! Licensed hospitals, EMS and long-term
care facilities must honor the IDPH Uniform
DNR Advance Directive/POLST document.
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Following POLST Orders
“A health care professional or health care
provider, or an employee of a health care
professional or health care provider, who in
good faith complies with a do-not-resuscitate
order made in accordance with this Act …may
not be found to have committed an act of
unprofessional conduct.”
- Subsection (d) of Section 65 of the Health Care Surrogate Act, 755 ILCS 40/65
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Q: If the POLST form is considered
a medical order, is it still
necessary to get a separate
order for a DNR?
A:
The instructions on a POLST form must be
followed as outlined. It is up to individual
institutions to determine if additional
formats will be used to communicate DNR
orders within the institution.
19
Q: Is the POLST form active upon
patient signature, or does it
require a physician’s signature?
A:
The form is not considered a medical order
until the physician has signed it.
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Q: Since the order is not valid
until a doctor signs the form,
how do you handle telephone
orders?
A:
This is based on the policies established
within your own institution. If your institution
has a policy that allows for telephone orders,
then you can accept a POLST order over the
phone. The physician should physically sign
the form as soon as possible.
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Q: What should I do with
previous IDPH DNR forms?
A:
The old DNR form is still valid! Review it with the
patient. If a POLST form is more appropriate for the
patient after careful conversation with a health care
worker, complete a POLST form. The updated IDPH
DNR/POLST form is a better form and should be used
moving forward.
22
Q: Why isn’t removing “DNR”
being proposed in the
legislation for the revised
POLST form?
A:
In the state of Illinois, we started with a DNR
form. The form was then changed to the IDPH
Uniform DNR Advance Directive . There are
legislative rules and reasons why this term
needs to stay in the title for now.
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Q: I was under the impression that
the POLST form is only for prehospital, and does not apply for
patients in the hospital. Is this
true?
A:
Yes, the POLST form is meant to serve as instructions for first
responders. It also represents the wishes of the patient
which are translated into a medical order set. So the
instructions that are put into place on the POLST form still
apply, unless reconsidered by the patient/substitute
decision-maker, even as the patient moves into the hospital
and to other healthcare settings.
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Q: Should all residents in a
nursing home have a POLST
form?
A:
Completing a POLST form is voluntary
• Using a POLST form is a practical way to capture both medical
orders and patient preferences, but cannot be required
• Residents typically meet criteria for using the form
• All staff should be trained on the form
• Everyone should know what to look for on the form
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POLL:
Has anyone in your organization been
formally trained on how to have a
POLST conversation?
Answers:
Yes, two or more staff have been trained to facilitate
a POLST conversation and complete the form
Yes, one staff member has been trained to facilitate a
POLST conversation and complete the form
No
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Q: When explaining the POLST form
to our residents, they tell us they
want to try CPR, but don’t want
any machines. How do we
respond to that?
A: Part A of the form is an instruction regarding treatment of a patient who has died,
who is in “cardiac arrest”, meaning: No heartbeat, No respirations , No consciousness. If
a person wants resuscitation attempted when dead, intubation will almost always be a
component of this treatment if resuscitation is successful.
In Part B, the intubation that is being described is in the context of respiratory distress or
pending respiratory failure, rather than in the context of cardiac arrest.
Most people who express these wishes are not aware that 1) intubation/mechanical
ventilation is almost uniformly a short-term outcome of a successful attempt at CPR, and
2) being “on machines” is often not a permanent “condition”. Once this is adequately
27 A.
explained to patients, they generally feel comfortable selecting CPR or no CPR in Part
Q: What if a patient does not
want to complete one of the
sections?
A:
That’s fine!
Cross out section and write “No Decisions Made”
– Doesn’t create false perception of patient wishes
– Stops someone else from just checking a box in the future
– Treat that section in the same way you would for any patient
who arrives without a form
– Start a discussion with patient or legal representative
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Q: Is Section B of the form required?
Some hospices are leaving the
section blank. If section B is left
blank is the form still valid?
A: If section A is completed, and section B or C are left blank – the POLST
form is a valid order in regards to what a first responder should do if the
patient has died.
If section B is blank, first responders will treat with all indicated medical
treatment.
If the patient does not want to complete sections B and C, rather than
leaving it blank, we suggest that a line be drawn through the sections and
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“no instructions” be written.
Q: If a person does not have a
POAHC, would it be possible to
use the Surrogacy Act Priority
Order to determine who can sign
the POLST?
A:
Yes, Illinois law (Illinois Healthcare Surrogate Act) directs us
to identify a substitute decision-maker for a patient who lacks
decision capacity. We are directed to first look for an agent with
POAHC. If there is no agent or POAHC and no other advance
directive document that gives adequate instructions for patient
wishes, we are then directed to refer to the Illinois Healthcare
Surrogate Act hierarchy - starting at the top and moving down.
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Q:
If a patient has completed a POLST form in
the hospital and then transfers to a SNF, does
the form need to be revised and signed by the
attending physician in the SNF? Or can we
honor the form from the hospital – given that
the patient doesn’t want to make any changes?
A: Any POLST form that has been appropriately completed needs to be recognized
in any medical setting.
We have seen situations where a patient is transferred with a POLST form, but a
different receiving physician is not aware of the existence of the form. One way to
reinforce awareness of the POLST order could be to have the receiving attending
physician complete another form (and, in doing so, confirm the discussion and
wishes by speaking with the patient and family). In any case, every institution must
have a way to communicate to all staff when there is a valid POLST form in place, no
matter who has signed the order, so that the patient’s wishes will be honored in an
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emergency.
Q: Is there an official color that
should be used for the POLST
form?
A: The POLST form is valid on any color paper. A brightly
colored form is recommended, and bright pink is the
standard color recommended across the country. The
bright pink color copies well without creating black
smudges.
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Q: Should a different color form
be used for the form if a
person wants to be
resuscitated?
A: Some nursing homes are addressing the potential for confusion about
whether the form is representing a patient’s wish to have CPR or whether
it is representing a patient’s wish not to have CPR by using different
colored paper for each. If a patient wants to be DNR the nursing home
copies the POLST form onto red paper, and when the patient wants to be
full code, green paper.
We are not endorsing this practice, but we think it is a clever way to
address this potential for confusion.
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Q: Can a nurse sign the physician’s
signature on the form, as he/she
would a verbal order, if the
physician is not available?
A:
Yes, if absolutely necessary. If it is
necessary to take a verbal order, the
physician should sign the form as soon as
possible, according to institutional
policy/procedure.
34
Q: Who can sign the POLST form
as a witness?
A:
The law says anyone over the age of 18
• IDPH website adds that witness “may include a family member,
friend or health care worker”
• Recommend avoiding appearance of conflict of interest
– When possible, someone not directly involved in patient’s
care, like another nurse, social worker, family member, etc.
however this is not required
35
Q: If the patient is confused, and the
POA lives out of town, is it acceptable
to call the POA and sign it as you
would a verbal order from a
physician?
A:
Ideally, the goal is to complete a POLST form when the
patient is still able to make decisions. This is not always
possible, however. Whether a clinician can accept a
verbal/phone consent from the appropriate decisionmaker to a POLST order should be determined by each
institution. Institutions can assess whether the practice
would be the same for POLST as for other consent
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forms.
Q:
I recently received a POLST form in a
hospital, and there was information
missing including DOB, gender and
address. Am I allowed to complete these
sections of the current form, or do I need
to complete a new form?
A:
This something you should check with the policy and
procedure person at your hospital.
While I am not a lawyer, I would personally think it would be ok to add
those items as long as you are confident you are dealing with the same
patient. When a change has been made, initial the addition and maybe
write a note in the medical record that you have made the change.
Ultimately, the decision is up to your institution.
37
Q: Couldn’t the use of red/green
paper increase the risk that the
form won’t be read and that an
error in color would lead to the
wishes not being followed?
A:
You could argue both sides of this point. This
practice is determined by policy of individual
institutions. Staff and first responder education
is critical in any case. The specific orders on the
form must be reviewed, rather than making
assumptions.
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Q: Who can authorize the
reversal of the POLST orders?
A: The patient, when decisional, or the appropriate
substitute decision-maker/legal representative can
revoke previous POLST orders.
Physicians and other practitioners may not reverse the
POLST orders unless authorized by the appropriate
decision-maker.
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Reversal of POLST Orders
Extreme care should be taken when a substitute decisionmaker wishes to reverse the direction of care previously
established by the patient, particularly if the patient had
selected a treatment plan that focused on comfort care.
A legal representative may make new decisions, but
generally should not be permitted to overturn decisions
already made by the patient ,unless there is evidence that
the patient had faulty information, misunderstood the
information given, or would have changed decisions based
on current developments in his or her medical condition.
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POLL:
How confident are you that staff in
your facility are able to interpret a
patient’s completed POLST form inthe
setting of a medical emergency?
Answers:
Completely
Somewhat
Slightly
Not at all
Does not apply
27
Q:
Should organizations use stickers on a
patient’s chart to indicate POLST orders?
A: A time-honored practice has been to signal critical patient
information (e.g., allergies, code status, etc.) by placing
stickers on the fronts of paper charts.
The more information included on a sticker, the more
chance there is for human error in transferring information
from the form. The POLST form is complex, and is used to
reflect patient wishes following a detailed conversation.
There is a risk of information being lost when “shorthand
summaries” could replace review of the actual form,
especially in an emergency.
Each institution should assess their own level of staff
understanding/education to determine policy/procedure
regarding this issue.
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Q: In a skilled nursing facility,
should the POLST form be
signed by each resident’s PCP
or our medical director?
A: This is my personal opinion, but I believe it depends on who would be
contacted in the case of an emergency. If the practice is to call the patient’s
primary care physician when there is a medical deterioration, it would make
sense that this physician is the one involved in the conversations who then signs
the form.
It is critical that there is communication with any treating physician about the
existence of the form for a patient who is deteriorating, to ensure the
instructions on the form are followed. The physician communicating with the
first responder needs to be aware of the instructions.
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For Updates and Current Information
• For more information on the National POLST
program, visit www.polst.org.
• For Illinois-specific resources, visit
www.POLSTil.org.
• Illinois POLST will be setting up Facebook and
Twitter accounts in the near future.
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Thank You
Dr. Julie Goldstein
polstil.org
POLSTillinois@gmail.com
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Telligen’s Contact Info
• Meghan Foley
– Project Assistant
– Meghan.Foley@hcqis.org
– 630-928-5805
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This material was prepared by Telligen, the Medicare Quality Improvement Organization for Illinois, under contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U. S. Department of Health and Human Services. The contents presented to not necessarily reflect CMS policy. 10SoW-IL-GEN-04/14-709