FAST FACT AND CONCEPT #178: The National POLST Paradigm Initiative

Authors: Patrick Dunn MD, Alvin H Moss MD, and Susan Tolle MD

POLST was developed as a one-page, advance care planning document, to be completed by health care professionals, together with a patient or surrogate decision maker. It was designed to follow patients through all care settings (e.g. hospitals, hospice, long-term care and home care) and as developed in Oregon, widespread buy-in was obtained to support its application across a community of health provider locations.

The actual form is divided into several sections:

• CPR decision: Resuscitate or DNR
• Medical intervention decisions : Comfort only vs. Limited additional interventions vs. Full treatment
• Antibiotics: none vs. limited use vs. use for life-prolonging intent
• Medically administered nutrition: none vs. defined trial period by tube vs. long-term use of tube
• Health care professional signature (patient/surrogate signature is strongly recommended or required, depending on state/region using form).

How it Works Completion of the brightly colored voluntary POLST form is recommended when a patient has a serious illness, generally with a life expectancy of one year or less. The health care professional turns the patient's values (expressed personally, through an advance directive or the patient's legal representative if the patient lacks decision-making capacity) into action by marking specific orders. The orders are valid when signed by a physician (or NP/PA depending on individual state regulations). Many state/regional POLST programs require the patient’s or legal agent’s signature in addition to the clinician’s to make the form valid. The POLST form is placed on the medical record and accompanies the patient across all care settings.

Data from completed research projects are available on the POLST website (www.polst.org). Key findings indicate that patients’ values are accurately reflected in the orders, that the orders are followed by first responders, that life-sustaining treatment orders beyond CPR (e.g. artificial nutrition) are useful, and that implementation can evolve to become a standard of care.

State/Regional Initiatives Numerous communities and states are developing, or have implemented, programs similar to Oregon’s, with the guidance of the National POLST Paradigm Initiative Task Force: West Virginia-Physician Orders for Scope of Treatment (POST); New York-Medical Orders for Life Sustaining Treatment (MOLST); Washington state, Wisconsin, and Pennsylvania-POLST.

The POLST website has sample downloadable forms (or contact the state/region’s program), downloadable education materials and videos, a map of states and regions using the form, and information on how to get started in building a coalition of health care professional organizations. A sample of most materials are available at no cost to help facilitate development of other POLST paradigm programs. There may be a low cost for larger orders to help cover expenses of a state or regional program’s coordinating center. The Center for Ethics in Health Care at Oregon Health and Science University coordinates the national initiative.

References

1. www.polst.org
2. Tolle SW, Tilden VP, Dunn P, Nelson C. A Prospective Study of the Efficacy of the Physician Orders for Life Sustaining Treatment. J Amer Ger Soc. 1998;46:1097-1102.
3. Hickman SE, Hammes BJ, Moss AH, & Tolle SW. Hope for the Future: Achieving the Original Intent of Advance Directives. The Hastings Center Report Special Report. 2005;35(6—Supplement):S26-S30.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Systems based practice

Keyword(s): Ethics, law, policy, health systems