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Physician Orders for Life Sustaining Treatment

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1 Physician Orders for Life Sustaining Treatment
What is POLST? Physician Orders for Life Sustaining Treatment PRESENTATION UPDATED APRIL 2011 POLST is an acronym that stands for Physician Orders for Life-Sustaining Treatment. It is a physician order that gives patients more control over their end-of-life care by specifying the types of medical treatment they want to receive. POLST: encourages communication between healthcare providers and patients. enables patients to make more informed decisions. clearly communicates these decisions to healthcare providers. As a result, POLST can: prevent unwanted or medically ineffective treatment. reduce patient and family suffering. help ensure that patient wishes are honored. Use of the form began in California in 2008, and became part of state law on January 1, 2009. [INSTRUCTORS: This slide presentation has been developed for your use. Please adapt to meet your needs and tailor to your audience and time allotted for presentation. If you have any questions, contact Erin Henke, POLST Program Manager with the Coalition for Compassionate Care of California at (916) or

2 Why POLST? Patient wishes often are not known.
The Advance Healthcare Directive (AHCD) may not be accessible. Wishes may not be clearly defined in AHCD. Allows healthcare providers to know and honor wishes for end-of-life care. So why do we need POLST in California? Studies have shown that patient wishes about care are often not known. Even when a patient has an Advance Healthcare Directive, it may not be accessible when needed. Also, Advance Directives are not always clearly defined. The POLST form is clear about wishes and easy to access and read. Plus, it is an actionable medical order that healthcare providers can follow. The POLST form allows healthcare providers to know patient wishes for end-of-life care and to honor them.

3 Case Study: What We Know
Let’s take a look at a typical story that may be familiar to you. Mr. Jones is an 83 year old man with severe congestive heart failure (CHF). He is living in a skilled nursing facility (SNF) after a hospital stay for pneumonia. He developed increasing shortness of breath and decreased responsiveness. The skilled nursing facility staff called 911 for patient transport to the hospital. The emergency department physician couldn’t find any code status information in the paperwork sent by the nursing facility, and wrote “Full Code.” Mr. Jones required intubation and was transferred to the intensive care unit.

4 Case Study: What We Didn’t Know
Here’s what we didn’t know: Mr. Jones had an Advance Healthcare Directive. It wasn’t with the paper work that was sent to the hospital. It was at his home. He had been asked about it on admission but his family hadn’t brought it in to add to his SNF medical record. Mr. Jones had talked with his family and the SNF staff about his desire not to go back to the hospital and that he didn’t want to receive any aggressive treatment. There was documentation of this in the nurses notes at the SNF, but not in any documentation that was sent to the hospital. Mr. Jones’ family could not be reached. [Note re: AHCD Kit image: © California Medical Association Published with permission of and by arrangement with the California Medical Association. More information regarding advance healthcare directives and related issues can be found in CMA’s California Physician’s Legal Handbook, which contains legal information on a variety of subjects of everyday importance to practicing physicians. CMA’s Advance Healthcare Directive Kit and California Physician’s Legal Handbook may be obtained from CMA Publications at (800) or CMA’s online bookstore at ©California Medical Association

5 Case Study: What Happened
AHCD not transferred with patient. DNR wishes not documented. Over-treatment against patient wishes. Unnecessary pain and suffering. So what happened in our story? The Advance Healthcare Directive was not transferred with the patient. The SNF didn’t have it so they couldn’t transfer it. Mr. Jones’ “Do Not Resuscitate” wishes were not documented in a way that was easily found by staff. When he was recently transferred from the acute care hospital to the SNF there were no code status orders with the transfer papers. Mr. Jones received over treatment which went against his wishes. Because of this he experienced unnecessary pain and suffering. There was a system-wide failure to document and honor the patient’s wishes. There was not a consistent, recognizable system in place. Every system had problems: acute care, Emergency Medical Services (EMS) and the SNF. [REFERENCE: Case study adapted from Lynn, Joanne; Goldstein, Nathan. Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwarranted Suffering. Annals of Internal Medicine, Vol. 138, Issue 10, May 20, 2003, pages ]

6 What is POLST? A physician order recognized throughout the medical system. Portable document that transfers with the patient. Brightly colored, standardized form for entire state of CA. So, what is POLST? [INSTRUCTORS: Pull out your POLST form to show] It is a physician order that is recognized throughout the medical system. It is a portable document that transfers with the patient from one care setting to another. It is easily distinguished by its bright pink color. It is a standardized form for the whole state.

7 What is POLST? Allows individuals to choose medical treatments they want to receive, and identify those they do not want. Provides direction for healthcare providers during serious illness. POLST provides direction for a range of end-of-life medical treatments so that healthcare providers can provide the treatments patients do want, and avoid those that they do not want. We’ll take a look at the POLST form itself in a moment.

8 Who Would Benefit from Having a POLST Form?
Chronic, progressive illness Serious health condition Medically frail Tool for determination “You wouldn’t be surprised if this patient died within the next year.” Who would benefit from having a POLST form? Anyone can have a POLST. However, POLST is designed for people who: Have a chronic progressive illness Have a serious health condition, or Are medically frail There are no age specifications. POLST can be used with both adult and pediatric patients. A helpful tool for determining who would benefit from POLST is the question … “Would you be surprised if this patient died within the next year.” This question reflects that determination of who’s appropriate for POLST is an art, not a science.

9 POLST History POLST development began in Oregon in 1991.
Expanded to more than half of US states. Let’s take a look at a brief history of POLST. It has existed for many years. POLST has been used in Oregon since 1991. It was developed initially for SNF patients who are often transferred from one care setting to another - mainly from the SNF to acute care and back to the SNF or to home. More than one million forms have been distributed in Oregon. POLST is used by all Oregon hospices and 95% of nursing homes. The use of the POLST form has now expanded to more than half the US – we’ll take a look at a map in a moment. Some states have used state regulation to help with POLST implementation. Others, such as California, have enacted POLST legislation to move POLST forward as a statewide standard of practice.

10 National POLST Paradigm Programs
Here is a map of POLST programs across the US as of January 2011. The dark pink/purple states have established POLST initiatives that are endorsed by the National POLST Task Force. The pale pink states have developing POLST programs. In most cases, these programs have a POLST-like form in place, but have not fully implemented it in the community or addressed the portability aspect of a POLST paradigm. As the map illustrates, some programs may only be present in part of a state, rather than statewide. The POLST system is developing around the entire country. Information about the National POLST Paradigm program can be found at Endorsed Programs *As of January 2011 Developing Programs No Program (Contacts) Designation of POLST Paradigm Program status based on information available by the program to the Task Force.

11 POLST Success Oregon study of 180 Skilled Nursing Facility (SNF) patients: POLST stated No CPR and Comfort Measures Only. Patient wishes were honored. More research available at There have been several studies showing how well POLST works in allowing providers to honor patient wishes. One study of 180 Skilled Nursing Facility residents in Oregon showed some excellent results. Only the residents whose charts contained POLST forms documenting “Do Not Resuscitate” and “Comfort Measures Only” were surveyed. The study found that none of these residents received unwanted CPR, care in the intensive care unit or ventilator support. Their wishes were honored. [REFERENCE: 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: ]

12 POLST in California The Coalition for Compassionate Care of California (CCCC) is lead agency. Support from California HealthCare Foundation. Grassroots efforts of local POLST coalitions and communities. Let’s take a look at what is happening with POLST in California. The Coalition for Compassionate Care of California is the lead agency for POLST in California, and is focused on implementing POLST as a community standard of practice. CCCC is working with more than 25 local POLST coalitions around the state that receive funding from the California HealthCare Foundation to support POLST outreach and education efforts in their communities. This grassroots approach to POLST implementation is one of the hallmarks of the California POLST paradigm.

13 POLST in California Effective January 1, 2009
POLST went through the legislative process as California Assembly Bill 3000. It was championed by Senator Lois Wolk of Yolo County and was supported fully by our legislators around the state – it passed unopposed. It was signed by Governor Schwarzenegger in August of 2008 and became law in California effective January 1, 2009. Effective January 1, 2009

14 POLST in California One form for entire state. Use not mandated.
Honoring form is mandated. Provides immunity from civil or criminal liability. Some of the key points in the bill to be aware of: There is one form for the entire state. This is an important requirement for POLST to work. How many forms do we have from one SNF to another, or one hospital to another that are the same? Not many! It is not mandatory for anyone to use the form, but honoring the form is mandatory! We must recognize the POLST form and honor the patient’s wishes. Must honor POLST even if ordering physician does not have admitting privileges at facility. The physician providing care conducts a new assessment of the patient, reviews POLST, and writes inpatient orders if admitted. Must follow POLST wishes except if contrary to generally accepted healthcare standards or medically ineffective treatment. An example would be a POLST form indicating CPR for a person who has metastatic cancer with renal failure. POLST law protects healthcare providers who comply in good faith with a patient’s POLST requests. [REFERENCE: AB 3000, Part 4, Section 7, Probate Code Section 4782 – “A healthcare provider who honors a request to forgo resuscitative measures is not subject to criminal prosecution, civil liability, discipline for unprofessional conduct, administrative sanction, or any other sanction...”]

15 POLST vs. Advance Healthcare Directive
POLST complements the Advance Healthcare Directive (AHCD). Both are legal documents. Does POLST replace the Advance Directive? Absolutely not! POLST aims to turn the values and wishes expressed in a person’s AHCD into actionable medical orders that can be easily understood and followed by healthcare providers, including EMS. In California, the term Advance Healthcare Directive includes both the Durable Power of Attorney for Healthcare and the Living Will. [REFERENCE: AB 3000, Part 4, Section 3, Probate Code Section 4780 (3) (c) “The healthcare provider, during the process of completing the POLST form, should inform the patient about the difference between an advance healthcare directive and the POLST form.”]

16 POLST vs. Advance Healthcare Directive
AHCD For seriously ill/frail, at any age For anyone 18 and older Specific orders for current treatment General instructions for future treatment Can be signed by decisionmaker Appoints decisionmaker POLST: Though anyone can have a POLST form, it is designed for those who are seriously ill or very frail – at any age. Is a medical order that documents wishes for treatment at this point in time; usually completed in a medical setting. Can be signed by the patient’s decisionmaker if the patient lacks decision-making capacity; can also be completed by the patient’s decisionmaker in consultation with the patient’s physician. There is one, standard form for California. Advance Healthcare Directive: Encourage everyone 18 years and older to have an AHCD. Is a legal document completed in advance that allows you to: make general statements about your healthcare wishes in the future, and appoint a healthcare decisionmaker to speak on your behalf. There is no universal AHCD form.

17 Advance Care Planning Continuum
Where Does POLST Fit In? Advance Care Planning Continuum Age 18 Complete an Advance Directive C O N V E R S A T I Update Advance Directive Periodically Diagnosed with Serious or Chronic, Progressive Illness (at any age) This slide shows where POLST fits into the Advance Care Planning Continuum. Starts at age 18 with completing an AHCD. Your AHCD should be updated periodically – check names, contact information, and healthcare wishes. If you are diagnosed with a serious or chronic, progressive illness at any age, talk with your physician about completing a POLST form. The goal is that your end-of-life wishes are honored. What is the word along the left side? Conversation. An ongoing conversation over the years with your healthcare decisionmaker, family, and healthcare provider is very important. Complete a POLST Form End-of-Life Wishes Honored

18 POLST vs. Pre-Hospital DNR (Do Not Resuscitate)
Similarities: Physician orders. Address Do Not Resuscitate. Intended for medically frail or those with chronic or serious illness. Let’s take a look at the similarities and differences between the POLST and the Pre-Hospital DNR. Both forms are physician orders. Both address Do Not Resuscitate if you are not breathing and your heart is not beating. Both are for the medically frail or those with chronic or serious illness. The Pre-Hospital DNR form was developed by the California Emergency Medical Services Authority to instruct EMS personnel to forgo resuscitation attempts in the event of a patient’s cardiopulmonary arrest. The form is designed for use in pre-hospital settings, such as: The patient’s home. Long-term care facilities. During transport from a healthcare facility. In other locations outside the acute care hospital.

19 POLST vs. Pre-Hospital DNR (Do Not Resuscitate)
Allows for choosing resuscitation Can only use if choosing DNR Allows for other medical treatments Only applies to resuscitation Honored across all healthcare settings Only honored outside the hospital There are differences between the two forms however. POLST: Allows for choosing resuscitation in addition to saying no to it. Allows for decisions about other medical treatments, such as artificial nutrition. Is honored across all healthcare settings (in the SNF, clinics, hospitals, home, EMS System, etc.) - the Pre-Hospital DNR is a medical order that is honored outside of the hospital only (home, assisted living, SNF, EMS System). POLST is more comprehensive than the DNR form. A DNR medallion or bracelet may be purchased with either a signed Pre-Hospital DNR form or POLST form. One resource for purchasing medallions/bracelets is MedicAlert – (888) ;

20 POLST vs. PIC (Preferred Intensity of Care)
Consistent form for CA PIC form is different in every SNF Is a medical order Is not a medical order; similar to a doctor’s note Honored across all healthcare settings Only honored within the SNF Let’s look at the differences and similarities between the POLST and the PIC (Preferred Intensity of Care) or PIT (Preferred Intensity of Treatment), which is used to document the wishes of SNF residents. The differences are that: The POLST is a consistent form throughout the state of California. The PIC form is different in every SNF. The POLST form is a medical order that is honored in all healthcare settings. PIC forms are not medical orders. They are usually signed by the physician but they are similar to a doctor’s note. And the PIC form does NOT transfer to other settings.

21 POLST vs. PIC (Preferred Intensity of Care)
Both include choices for medical interventions. POLST can replace the PIC form at SNF. Both of these forms do include choices for medical interventions. The POLST form can replace the PIC form in SNFs.

22 Let’s take a look at the form itself – please pull out your copy of the form and we will look at the different sections. What stands out about the look and feel of the form? Ultra Pink Card stock 65# paper If making copies, please use Ultra Pink paper so POLST is easily found and recognized. POLST will be honored on any color paper, however.

23 POLST is a two-sided form, with all the required information located on the front of the form. It is important, however, to complete all the sections on the back as well, including the patient demographic information. And remember to fax or copy both sides. Let’s take a closer look at the different sections of the form…

24 CA POLST Form – Front Side
Here we see the top section of the front side. What does it say at the top in the black box? HIPAA permits disclosure of POLST to other healthcare providers as necessary. What is the logo in the upper left hand corner? California Emergency Medical Services Authority – this means that EMS must honor the form and take action based on the patient wishes stated on the form. Below that is the effective date of the form. Let’s take a look at the paragraph next to the EMSA logo: First follow these orders, then contact physician. This is a Physician Order Sheet based on the person’s current medical condition and wishes. Any section not completed implies full treatment for that section. Full treatment is the standard of care. A copy of the signed POLST form is legal and valid. POLST complements an Advance Directive and is not intended to replace that document. Everyone shall be treated with dignity and respect. These are critical and important considerations for anyone using the form. In the upper right corner, there is a place to document the patient’s name, date the form is prepared, patient’s date of birth and medical record number. It’s very important to date the POLST form so the most recent version can easily be identified in the case of conflicting documents.

25 Section A: CPR Let’s take a look at Section A. What does Section A address? Cardiopulmonary Resuscitation (CPR) What must be happening with the patient for us to be taking action on this section? The person has no pulse and is not breathing. Notice also that it states that when NOT in cardiopulmonary arrest, follow orders in Sections B and C. It’s important for the patient/family to understand that if you have no pulse and are not breathing, you are dead and not doing CPR allows a natural death. Let’s take a look at the two choices: Attempt Resuscitation/CPR – the key word here is attempt. As part of the conversation about POLST, it is important to educate the patient/family about CPR and the statistics about success. What does it say next to Attempt Resuscitation/CPR? Selecting CPR in Section A requires selecting Full Treatment in Section B – we’ll take a closer look at why that’s there in a minute. The other choice is Do Not Attempt Resuscitation/DNR. What does it say next to this? Allow Natural Death. One of the instructions on the back of the form also indicates that “If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a person who has chosen Do Not Attempt Resuscitation.”

26 Section B: Medical Interventions
Section B addresses medical interventions. The first thing is to establish that the patient is alive. If the patient has a pulse and/or is breathing, then treat as directed in Section B. A person must have a pulse to be breathing, but sometimes it is weak and difficult to detect. There are three check boxes in this section, as well as a place to write in additional orders. [Read through the options if appropriate for your audience] Comfort Measures Only – this doesn’t mean ‘no treatment’, but that 100% of care is focused on comfort; also note when to transfer a patient – only if comfort needs cannot be met in current location. Limited Additional Interventions – includes a check box for no transfer to hospital for SNF residents. Full Treatment With Limited Medical Interventions and Full Treatment, antibiotics are given in hopes of curing an infection. Antibiotics generally are not considered Comfort Measures, but may be used in Comfort Measures to promote comfort, for example, if the patient has a urinary tract infection. Manual treatment of airway obstruction = Heimlich maneuver (abdominal thrusts for choking) Non-invasive positive airway pressure = includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations. Cardioversion = restoring the heart’s rhythm to normal by means of electrical shock or medications. Let’s take a look at how Sections A and B work together.

27 Diagram of POLST Medical Interventions
CPR DNR Comfort Measures Limited Interventions Choosing “Attempt Resuscitation / CPR” in Section A requires choosing “Full Treatment” in Section B: Medical Interventions. It is not acceptable to request “Attempt CPR” and “Comfort Measures Only”. If a person wants CPR, they must be willing to have ACLS (Advanced Cardiac Life Support) guidelines followed, which usually includes intubation and care in the ICU. “Do Not Attempt Resuscitation / DNR” may be chosen with any of the Medical Interventions in POLST Section B. “DNR” may be chosen with “Full Treatment.” This applies to the patient who has a pulse and/or who is breathing and wants aggressive medical interventions, but who doesn’t want to be resuscitated if found without a pulse or not breathing (they have died). It is important to address length of treatment, severity of illness, and prognosis with this option. Ask the patient, “If you did not get better and doctors thought your chances of a good recovery were very poor, would you want to be kept alive on the ventilator?” If the patient does not want to be kept on life support, “Defined trial period. Do not keep me on prolonged life support.” can be written in under Additional Orders in Section B. Other possible additional orders might relate to dialysis, chemotherapy or blood transfusions. Module 4: The POLST Conversation includes discussion regarding long-term intensive medical treatment. Full Treatment* *Consider time/prognosis factors under “Full Treatment” “Defined trial period. Do not keep on prolonged life support.” 27

28 Section C: Artificial Nutrition
Section C addresses Artificially Administered Nutrition. Food will always be offered by mouth if feasible and desired by the patient. Patients may choose between three options related to artificial nutrition: No artificial means of nutrition, including feeding tubes. Trial period of artificial nutrition, including feeding tubes. That is not decided ahead of time; the physician will decide what is appropriate for the individual at the time. Also, feeding tubes includes Total Parenteral Nutrition, or TPN. Long-term artificial nutrition, including feeding tubes. Studies have shown that for individuals with late stage dementia or advanced terminal diseases, pneumonia and pressure ulcers are not prevented with tube feeding. The POLST Conversation goes into detail about the benefits and burdens of artificial nutrition. For more information, see Tube Feeding: A Guide for Decision-Making available at

29 The POLST Conversation
POLST is not just a check-box form. The POLST conversation provides context for patients/families to: Make informed choices. Identify goals of treatment. This form is not just a check box form. A conversation with a healthcare provider is needed to discuss options for each individual patient. For those of you who will be helping patients/families with this form, there is additional information about how to facilitate a POLST conversation in Module 4. Instead of simply asking, “What do you want?,” our role is to facilitate the POLST conversation. Medical examples of what could happen in the future are used to help clarify goals of care and focus the conversation. For example, saying, “If you had a bad pneumonia…” transitions the discussion into Section B, Medical Interventions.

30 Section D: Information and Signatures
Notice the check boxes for who the POLST form was discussed with: The patient – patient has capacity. A legally recognized decisionmaker. A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of minor, closest available relative, or person whom the patient’s physician believes best knows what is in the patient’s best interest and will make decisions in accordance with the patient’s expressed wishes and values to the extent known. We will expand on this in the next slide. There are also check boxes for “Advance Directive dated ______ available and reviewed,” “Advance Directive not available,” and “No Advance Directive.” This highlights the importance of asking for and reviewing a patient’s Advance Directive. Ask participants: What two signatures are needed for this form to become a medical order? The patient/legally recognized decisionmaker and the physician. Read description to the class following Signature of Patient or Legally Recognized Decisionmaker. What does it say in the bottom black section of the form? Send form with person whenever transferred or discharged. This is an important reminder. The original POLST form travels with the patient.

31 Who Can Speak for the Patient?
Surrogate decisionmaker/agent Parent, guardian, conservator Closest available relative The legally recognized health care decisionmaker includes anyone recognized under California law, including: The person named in advance directive (whether it is a verbal advance directive, which is time limited, or a written advance directive). [REFERENCE: Probate Code Sections 4671 & 4711] Parent of a minor, a guardian, or a conservator If none of those people exist, then health care providers may turn to the “closest available relative” to make decisions. This term was established in case law and the court did not define it. [REFERENCE: Cobbs v Grant, 8 Cal3d 229, 244 (1972)] In the case of SNF residents without known relatives, the multi-disciplinary Eppel committee is authorized to consent only to affirmative treatment on behalf of the patient – they may not consent to withholding or withdrawing treatment. Thus, with POLST, they may only select CPR, Full Treatment, and Long-Term Tube Feeding. Many acute care facilities have policies on decisionmaking with the unrepresented patient – check with your individual facility. Healthcare providers should turn to the legally recognized healthcare decisionmaker only if the patient lacks capacity or the patient has indicated that the decisionmaker’s authority begins immediately. [REFER TO RESOURCES: CHA Consent Handout, CCCC Handout on decisionmaker]

32 CA POLST Form – Back Side
The top of the back of POLST form includes information for the: Patient Healthcare provider preparing the form And an additional contact – if the decisionmaker is not the signor or is not the healthcare agent on the advance directive, capture their information or another contact person here. This information is purely informational and is not required to be completed in order for the POLST form to be valid. This does not appoint a healthcare decisionmaker, nor is the healthcare provider listed on the form signing the form as a witness.

33 Who Can Help Complete POLST?
Healthcare providers – “licensed, certified, or otherwise authorized to provide healthcare in the normal course of business.” Best practice suggests use of those trained in the POLST Conversation: Physicians Nurses Social Workers Chaplains Social Service Designees Who can help a patient complete a POLST form? We refer to people who help patients complete a POLST form as POLST Initiators, and those who carry out POLST orders are referred to as POLST Implementers. POLST Initiators: POLST law stipulates that the POLST form “shall be completed by a healthcare provider.” [REFERENCE: AB 3000, Part 4, Section 3, Probate Code Section 4780 (3) (c)] The term "healthcare provider" is defined by law as "an individual licensed, certified, or otherwise authorized or permitted by the law of this state to provide healthcare in the ordinary course of business or practice of a profession.“ [REFERENCE: Probate Code Section 4621] Best practice would include those who are trained in the POLST Conversation, including: Physician – MD or DO Nurse Social Worker Chaplain Social Service Designee if trained in the POLST conversation The key is to explore with patients and families their goals of care, and this requires a good understanding of the patient’s medical condition and what to expect as their disease progresses. Any questions should be referred for discussion with the patient’s physician. POLST Implementers include EMS and Emergency Department staff, as well as others carrying out the orders documented on the POLST form, and delivering medical treatment to the patient.

34 Directions – Completing POLST
The back of the form also includes abbreviated directions on how the form is to be filled out and additional instructions for healthcare providers. Completing the POLST: Completing a POLST form is voluntary. California law requires that a POLST form be followed by healthcare providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient is assessed by a physician who will issue appropriate orders. When available, review the Advance Directive and POLST to ensure consistency and update forms to resolve conflicts. POLST must be signed by patient or decisionmaker and physician to be valid. Verbal orders may be obtained with follow-up signature by the physician in accordance with facility/community policy. Physician engagement in the POLST conversation is essential, including those times when verbal orders are urgently needed. A FAXed physician signature is acceptable. If a translated form is used, attach it to the signed English POLST form.  Photocopies and faxes of signed POLST forms are legal and valid.

35 Directions – Using POLST
Any incomplete section of POLST implies full treatment for that section. Section A: If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a person who has chosen “Do Not Attempt Resuscitation.” The person who has chosen DNR and Full Treatment might want a defibrillator if they are still alive (breathing) but not if they have died and are pulseless and not breathing. Section B: When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture). Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations. IV antibiotics and hydration generally are not “Comfort Measures.” Treatment of dehydration prolongs life. If person desires IV fluids, indicate “Limited Interventions” or “Full Treatment.” Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel.

36 Reviewing/Modifying/Voiding POLST
Directions – Reviewing/Modifying/Voiding POLST This section includes specifics on reviewing, modifying and voiding the POLST form. We will go over the details on the next slide.

37 When Should POLST be Reviewed?
Transfer from one care setting to another. Change in patient’s health condition. Patient’s treatment preferences change. Patient Care Conference. POLST should be reviewed when any of the following occur: The person is transferred to a different care setting. For example: home to acute care, SNF to acute care, acute care to home, etc. There is a substantial change in the person’s health condition. The person changes his/her mind about any of their treatment preferences. At quarterly care conferences at skilled nursing facilities and at any patient care conference, the POLST should be reviewed and verified or changed as needed.

38 Can POLST be Changed? Individual with capacity can request alternative treatment or revoke a POLST at anytime. Legally recognized decisionmaker may request change based on condition change or new information regarding patient wishes. Can POLST be changed? A patient with capacity can, at any time, request alternative treatment. A patient with capacity can, at any time, revoke a POLST by any means that indicates intent to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D, writing ‘VOID’ in large letters, and signing and dating this line. The legally recognized decisionmaker may request to modify the orders, in collaboration with the physician, based on the known desires of the individual, or if unknown, the individual’s best interests. a change to the POLST form only if the patient lacks capacity, and may do so in consultation with the physician, if there is a change in the patient’s condition or if there is new information about the patient’s wishes. A new POLST may then be initiated. The voided POLST is filed in the chart.

39 Where Should We Keep POLST?
Original pink POLST stays with patient At SNF/Hospital: File in medical chart (with AHCD). Send original with patient upon return to home/SNF/hospital. Keep copy if resident transferred; review POLST upon resident’s return. The bright pink POLST form stays with the patient at all times. Consider treating POLST as part of the patient’s belongings. SNF or Hospital: POLST form should be kept in the resident’s/patient’s medical chart – file with AHCD. May be scanned into the electronic medical record. POLST goes with the patient from one care setting to another – keep copy in chart and send original with patient. When/if patient returns to SNF, always review whether there were any changes made to POLST on file. It is helpful to keep the POLST, along with the AHCD, in a plastic sleeve.

40 Where Should We Keep POLST?
At home: Post in easy-to-find location (with AHCD). Give to EMS to transport with patient. Home: In the home setting, patients/families should be instructed to keep the POLST in an easy-to-find location, for example on the refrigerator or hanging on a wall by their bed, or with their medications. The POLST goes with the patient if transported by ambulance; family should give the POLST to the Emergency Medical Services personnel. The development of a POLST registry for California will be evaluated in 2011/ Oregon launched its POLST registry at the end of 2009, so we will learn quite a bit from their experience. The idea of a POLST Wallet Card has also come up and will be explored in the future. In the meantime, patients requesting DNR on their POLST form may obtain a DNR medallion or bracelet.

41 POLST: Depth of the Process
POLST is more than a form. POLST: Facilitates rich conversations with patients/families. Complements the AHCD. Incorporates the depth of comfort care. POLST is not just “a pink piece of paper.” The POLST Conversation is a rich discussion of patient values and preferences for intensity of medical treatments. POLST does not replace the AHCD. During the POLST Conversation, completion of an AHCD and naming a decisionmaker is strongly encouraged. Providing comfort measures to everyone is a key foundation of the POLST process.

42 California POLST Project
The Coalition for Compassionate Care of California (CCCC) provides leadership and oversight for POLST outreach activities in California, with support from the California HealthCare Foundation. C oalition for C ompassionate C are of The Coalition for Compassionate Care of California is the lead organization for POLST efforts in California, with financial support from the California HealthCare Foundation. Note the four ‘C’s in the lead organization’s name. C alifornia 42

43 California POLST Project
Translating an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for medical treatment. POLST Conversation A rich conversation with each individual patient Community Collaboration Integrating POLST into the community standard of care Consistent Form Standardized form recognized across care settings The California POLST Project translates an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for treatment. We have taken the four C’s and applied them to the key elements of the POLST process. The 4 C’s show the depth and breadth of the POLST process in California: POLST Conversation Consistent form Comprehensive education Community collaboration Comprehensive Education To promote excellent conversational skills with patients and families 43

44 ©California Medical Association 2009
California POLST Form Available at Translations available May be purchased from: (bulk forms/paper) (POLST Kit) The current copy of the form is available to download at Translations are also available in Chinese, Farsi, Hmong, Korean, Russian, Spanish, Tagalog and Vietnamese. English form must be signed for healthcare providers to be able to follow the orders. Translated form should be attached behind the English version. A Braille POLST form is also available. [Note re: POLST Kit image: © California Medical Association Published with permission of and by arrangement with the California Medical Association. More information regarding POLST and related issues can be found in CMA’s California Physician’s Legal Handbook, which contains legal information on a variety of subjects of everyday importance to practicing physicians. CMA’s POLST Kit and California Physician’s Legal Handbook may be obtained from CMA Publications at (800) or CMA’s online bookstore at ©California Medical Association 2009

45 Focus on the conversation
California POLST Form Print on Ultra Pink, 65# card stock paper Copies/faxes on any color paper are acceptable Focus on the conversation POLST should be printed 2-sided on Ultra Pink, 65 pound, card stock paper. This is the standard for California, and what providers are trained to look for. Copies and faxes on any color paper are just as valid as the original. The focus should be on the conversation about choices, not just the form and filling it out.

46 POLST Resources Provider and Consumer Brochures FAQs Videos
There are several educational materials available for healthcare providers who will be leading these conversations, as well as for consumers. Brochures for consumers and healthcare providers Frequently asked questions (FAQs) for consumers and healthcare providers POLST at Work in California video and the Facilitating Meaningful Conversations about Goals of Care, a video for healthcare providers that demonstrates how POLST is introduced using eight different clinical scenarios.

47 POLST Resources Model policies and procedures
Standardized educational curriculum Local POLST coalitions Model policies and procedures are available for acute care, skilled nursing facilities and hospice. A standardized curriculum including seven educational modules has been developed and used to train more than 450 POLST Trainers in California. Several POLST coalitions are actively working on POLST implementation in communities throughout the state. Coalition contact information is available online. All materials can be found and downloaded for your use from CCCC at

48 Questions? What questions do you have?
INSTRUCTORS: Feel free to add your contact information to the slide. For more information/assistance answering questions, contact Erin Henke, POLST Program Manager at (916) or Instructor may go through the objectives and ask review questions of the group: What does the POLST acronym stand for? Physician Orders for Life Sustaining Treatment. What type of patient is POLST designed for? Chronic, progressive illness; seriously ill; medically frail; the “surprise question.” State a difference between an AHCD and POLST. AHCD names a decisionmaker. POLST is a physician order. What is the difference between POLST and PIC? POLST is medical order and is recognized in all healthcare settings. List two signatures required on the POLST? Patient and physician.

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