1. IDPH Uniform Practitioner Orders for Life-Sustaining Treatment
(POLST) Form
An Introduction for Emergency Medical Services

2. Objectives
Explain the POLST Paradigm and how patient wishes are documented in a standard form
Describe how POLST form builds upon and improves existing advance directives
Advocate for patients by accurately interpreting IDPH POLST form instructions and taking appropriate action

3. Evolution of the IDPH POLST Form
2015
2016
2000
2007
2006
2005
2013
Evolution of the IDPH POLST Form
“Orange”
DNR Form
IDPH Uniform DNR “Order Form”
IDPH Uniform DNR “Advance Directive”
POLST Language Added
“Practitioners” Who Can Sign Medical Order are Expanded
The form started in 2000 as the original “orange DNR form” and has gone through a number of changes over the years to reach its current status as a nationally recognized “POLST form”. This is the sixth version and offers patients and providers both more options and more concrete guidance.
2000: 1st Illinois EMS DNR “orange form”; only for EMS, order had to be rewritten at each new facility
2005: IDPH Uniform DNR Order form - applied to all facilities
2006: Confusion if form had to be used for every in-hospital DNR order (no); renamed IDPH Uniform DNR Advance Directive
2013: Remained IDPH DNR Advance Directive, but used shorthand POLST “paradigm” for life-threatening emergencies
2015: IDPH DNR/POLST- Other practitioners can sign
2016: DNR removed from title; care options redefined
IDPH Uniform “POLST form” 6

4. Various forms of the past
Released 2015
Released 2006
Released 2000

5. Version #6 – Issued April 2016 Version #6 – Issued April 2016
Instruct group to open to the new POLST form.
At this point tell them that page 2 is NOT REQUIRED TO BE FILLED OUT TO BE VALID.
As you can imagine, if staff were to look at a completed form and automatically assume it indicated that the patient was DNR, a patient who wishes to be resuscitated might be inappropriately allowed to die from cardiac arrest without intervention, which would be a grave medical error.
The form is now officially called the “Illinois Uniform POLST Form”, and will no longer carry “DNR” in the title. This is a crucial update, because when the form was called a “DNR” form, it reinforced a DANGEROUS MISUNDERSTANDING that the form is only used for patients who do NOT want CPR in case of cardiac arrest.
In fact, this form may also be used by patients who WOULD ACCEPT CPR in case of cardiac arrest and also have preferences as to the extent of care they wish to receive if emergency services are needed.

6. Current Advance Directives in Illinois:
Rely on Advance Directives only if the patient cannot make medical decisions:
Current Advance Directives in Illinois:
Patient
POLST
Directions for Emergency Care
Power of Attorney for Health Care
Agent (rarely contains directions for physician)
Mental Health Treatment Declaration
Directions + Agent (for physician)
Living Will
Directions (for physician)
Apply to ALL healthcare providers, including EMS

7. IDPH POLST form and national POLST standards
New IDPH form modified to align with national POLST standards used in other states
In Illinois, POLST stands for “Practitioner Orders for Life-Sustaining Treatment”
Practitioners authorized to sign form: Physicians, Advance Practice Nurses (APNs), Physician Assistants (PAs), and medical residents (≥ 2nd year)

8. Intended use
To be discussed with patients for whom death within a year is expected - those with advanced, serious illness and frail elderly
FORM IS VOLUNTARY: Language added stressing that the form cannot be required of any patient and is completely voluntary

9. Benefits of revised IDPH POLST Form Promoting Patient-Centered Care
Provides medical orders that must be followed by healthcare providers if within their scope of practice
Easily recognized standardized form for the entire state
Form is intended to go with patient from care setting to care setting (coordinated care)

10. All previous versions still VALID!
Older versions of form still in use (OK)
A valid form does not expire and should be honored
Form should travel with patient at all times and be readily accessible to healthcare personnel

11. What if 2 or more different forms are presented?
Newest valid form voids past forms
Follow instructions on form with most recent date and all required elements
EMS is not responsible for investigating presence of other forms - consider form presented to be most current

12. Revised (2016) IDPH POLST Form 3 Primary Medical Order Sections
If pulseless and nonbreathing: CPR wishes
Attempt resuscitation
Do Not Attempt resuscitation (DNR)
If pulse or breathing present: Care wishes
Full Treatment
Selective Treatment
Comfort Focused
Medically Administered Nutrition
Acceptable
Trial Period
None
Update
This slide shows the general outline of decision categories in the 2016 IDPH POLST forms

13. Section A Resuscitation/CPR: Yes or No
Attempt resuscitation/CPR and DNR options now on same line to avoid possibility of checking the wrong box

14. Section “A”: Cardio-Pulmonary Resuscitation
Patient found pulseless and not breathing
If “Attempt Resuscitation/CPR” box checked: Start CPR and full cardiac arrest care per local protocol
If “DNR” box checked: Do NOT begin CPR

15. Attempt CPR is the Default Why use the form to request CPR?
Elderly and those with disabilities may fear they will not receive same emergency care as others
May have created a POLST form marking DNR box during a serious illness. May create a new form if health improves or they desire to reach a milestone moment; now selecting attempt CPR.

16. Section “B”: Medical Interventions
Do Not Resuscitate does NOT mean Do Not “Treat”
This is for the “pre-arrest” patients. This is the person that if we do nothing will end up in full cardiac arrest. So what this section does for us is it tells us how aggressive the patient wishes us to be.
If patient found with a pulse and/or is breathing:
Section B explains extent/intensity of desired care

17. Section “B”: Medical Interventions
If a patient is found in “full cardiac arrest” (no pulse/not breathing), the chance of them surviving neurologically intact is less than 50%. For this reason, many patients would likely choose the Do Not Attempt Resuscitation/DNR box in Section A.
However, the same patient may also believe that if they are choking or having a severe asthma attack and are in need of an in-line neb or an advanced airway that would save their life and preserve their neurologic function, they may choose this option. In Section B, Full Treatment is not meant to also apply to cardiac arrest management.  
Another example: let’s say someone has pneumonia and develops septic shock.  They are willing to have all medical treatment aimed at reversing these processes.  But given their severe, inoperable CAD, they understand that, should they have a cardiac arrest, even as a result of the sepsis, their prognosis for recovery significantly lowers.  So they would like to try antibiotics, pressors, be in the ICU, on a vent if necessary, but would not want ACLS should their heart stop.  That would be a situation where they would mark No CPR in section A and Full Treatment in Section B.
Full Treatment: Provide all care per protocol; transport if indicated
Either box may be marked in Section A ,which is for full cardiac arrest.
“Full Treatment” applies to non-cardiac arrest emergencies.

18. Section “B”: Medical Interventions
An example of using this option is a patient with heart failure having severe shortness of breath. They may want a trial period of CPAP/BiPAP but do not want to be intubated. This patient may be far more comfortable if we can provide noninvasive pressure support ventilations and/or position them appropriately to relieve their distress. King LTD, LMA, Combitube are other examples of advanced airways that the patient generally intends to refuse if this box is marked.
CPAP and BiPap are only indicated if the patient has adequate respiratory effort. A BVM is used by rescue personnel if the patient requires assisted ventilations..
Selective Treatment: Comfort-focused treatment plus basic medical interventions
IV fluids; IV meds as appropriate
Do NOT intubate: May use CPAP, BiPAP, BVM
Transport to hospital if indicated

19. Section “B”: Medical Interventions
A good example of this would be a hospice patient. “Please keep me out of pain but let me die at home.” One of the problems that EMS personnel face is being called to a home because the family does not know what to do when the patient deteriorates and end of life appears imminent. EMS responds and the family requests help, but they do not know what that help should be. EMS usually has to transport the patient even though patient’s wish is to not be transported. There is now a caveat written into the form states, “Transfer to hospital only if comfort needs cannot be met in current location.”
Comfort Focused Treatment
Treat pain (per routes allowed by scope of practice), O2, suction; manual airway obstruction maneuvers
No transport unless comfort needs cannot be met in current location

20. Section “B”: Medical Interventions
EMS can only provide interventions entered under “Additional Orders” if they are within their scope of practice. If these orders are questionable, contact on-line medical control for direction.
This does not count as a check mark.
So when would this be used?
Comfort Measures patients – use of pain medications and antiemetics but no cardiac medications……
Limited Additional patients – no defibrillation, no oral or nasal airways, IV fluids for hydration only……
Intubation and Mechanical patients – trial of intubation and mechanical ventilations for X days only if able to be neurologically intact.
these is just a few examples of what we may find in the additional orders.
Optional Additional Orders - used to customize form for individual medical conditions when necessary
Orders implemented must fall within local protocols and practitioner scope of practice

21. Section “C”: Medically Administered Nutrition
EMS providers can usually ignore this section
Provides clear direction to avoid contested care as happened in Terri Schiavo case in Florida
For patients with TPN/tube feedings needing transport, contact Medical Control

22. Section “D”: Documentation of Discussion
Anyone can witness the DNR/POLST form. The only restriction is that it cannot be the “Primary Care Giver”. The primary care giver is the practitioner that is directing the patient’s care. All other medical personnel are carrying out the practitioners orders so can witness the form if needed.
Need 2 signatures here
Patient, agent (POA), or healthcare surrogate
Witness to consent
If consented by patient’s legal representative, supporting documents verifying agent powers are NOT needed by EMS

23. Section “E”: Signature of Practitioner
Must have practitioner’s name, signature, and effective date to be valid
Practitioner’s signature may be written by a nurse who adds her/his own initials - acceptable and form is valid

24. Requirements to make form valid
Patient name
Resuscitation orders (Section “A”)
3 Signatures
Patient or Legal Representative
Witness
Practitioner
Date
All other information is optional

25. Who can revoke these orders?
Patient at any time
Other situations more complicated and may take time to resolve
If any doubt or dispute, call OLMC
A POA/Surrogate should generally not overturn decisions made, documented, and signed by a patient
EMS responders are legally protected if they follow orders on a valid form in good faith
A POA or surrogate could very well argue that a patient who wanted “full treatment” before has now deteriorated to the point where s/he would only want “selective “or “comfort” measures. That change in status can usually be quickly approved by OLMC. However, if a POA or surrogate wants to overturn a comfort-care order and escalate to Full Treatment, that decision must be carefully reviewed with OLMC. A POA/surrogate is supposed to act according to the patient wishes and not their own.

26. If yes: The POA/surrogate may change the order and/or care wishes
What if a POA or Surrogate disputes a valid POLST order to which they previously consented?
Determine if person disputing order is the original consenting POA or Surrogate
If yes: The POA/surrogate may change the order and/or care wishes
If no: Follow orders on the POLST form; contact OLMC for further direction

27. Are EMS personnel at legal risk for following a POLST Order?
“A health care professional who in good faith complies with a do-not-resuscitate order made in accordance with this Act is not, as a result of that compliance, subject to any criminal or civil liability, except for willful and wanton misconduct, and may not be found to have committed an act of unprofessional conduct.”
Illinois Health Care Surrogate Act

28. Reverse Side: General Information May provide useful contact phone numbers.
This side is purely option. EMS personnel do not need to review or take action on any of these notations.

29. Quick Recap CPR Yes, No; Care wishes?
Yes or No?
Care wishes?
Ignore

30. Check for understanding
An unconscious adult presents in bed at home. The patient is not breathing but does have a weak pulse. An IDPH POLST form is on the fridge. What part of the form is most relevant right now?
Section A: Has the patient marked DNR?
Section B: How aggressively does the patient want to be treated?
Section C: Has the patient consented to artificial nutrition?
Answer is B. Because the patient still has a pulse, section A does not apply at the moment.
Section C discusses the placement of a feeding tube and is not immediately relevant here.

31. Answer
Answer is A. Patient is not breathing and does not have a pulse so sections B and C would not apply at the moment.
If the neighbor is not a healthcare provider they would not be expected to know about or follow the POLST form. As long as the neighbor has not restored breathing or a pulse, the EMS provider would still follow the POLST instructions under section A.

32. Form printing
Recommended that form is printed on pink paper to make it easier to see
Completely executed form is valid, regardless of color
Photocopies are acceptable!
Originals are not necessary. A healthcare worker may presume in the absence of knowledge to the contrary that a POLST form with all the mandatory elements noted or a copy of that form is a valid.

33. So, to sum it up
EMS personnel must follow a valid IDPH POLST order relative to resuscitation attempts in cardiac arrest situations
A valid POLST order should be honored relative to extent of care if patient has a pulse or is breathing unless compelling circumstances cause OLMC to direct EMS personnel to provide alternate care

34. This presentation for the POLST Illinois Taskforce has been made possible by in-kind and other resources provided by: