POLST Skills Development - Sharmon Figenshaw and Bruce Smith

Physician’s Orders for Life-Sustaining TreatmentSharmon Figenshaw, ARNP, Bruce Smith, MDWashington POLST Task Force Co-Chairs

POLST Update for Professionals


What is POLST?

“Portable” medical orders for treatment decisions, including end-of-life care; conforms to medical standards of care.

Defines patient preference for health care options based on current physical/medical condition.

POLST can translate an advance directive into physician’s orders or reflect change in preferences based on change in medical condition.


What is POLST?

Patient & provider shared decision-making model: Brings together patient goals/values and practitioner-guided consideration of current medical condition.

Translates patient wishes into orders that can be followed by EMS (and hopefully other bedside providers).

Options include range of care from full code/full measures to DNR/comfort.

Power and portability

REMEMBER: Conversations for goals of care come first!


Philosophy of POLST

Individuals have the right to make their own health care decisions. These rights include:

Making decisions about accepting or refusing life-sustaining treatment.

Having their decisions honored by health care providers. Comfort care while having wishes honored.

POLST allows people to “opt out” of the default “full code” of standard emergency/medical care.


POLST: Who Should Have One?

Who should have POLST form: Persons with advanced or chronic illness, or frailty. Condition for which resuscitation is inappropriate including when

survival is unlikely. Anyone who “you wouldn’t be surprised” if they were to die

within the next year.

Good clinical documentation Especially when surrogates are decision makers.


POLST: Who Could Have One?

Anyone choosing: To limit medical treatments Do Not Resuscitate/No Code/Allow Natural Death Advanced age >80 years old (without mental instability)

This covers our healthy seniors who want to make sure that they do not receive unwanted CPR or burdensome hospitalizations.*

*There is some debate about this in religious circles.

It is important to remember: POLST is always voluntary!

How an Advance Directive and POLST Form Work Together


Establish Goals of Care

Shared decision-making based on the patient’s values and goals in light of their current medical condition:

“What do you understand about your condition?” Informed consent: Patients need information about risks

and benefits of life-saving measures! “What are you hoping for? What might you be afraid of?” Initiate in the hospital by the time of discharge if not

already done by primary care provider. “How would you like to live your life?”

How POLST Works

The POLST Form (Front)

Medical Condition/Patient Goals

A simple description of medical condition A direct statement of the patient/family’s goals in their own

words is one of the most important pieces of information we can gather.

This may guide care decisions when nothing else can.

Agency Info/Sticker

Write in, or place sticker here for an agency.


Part A: Code Status

Instructions regarding Cardiopulmonary Resuscitation (CPR): Includes EMS

Patient has no pulse and is not breathing

CPR/Resuscitate Do Not Attempt Resuscitation (DNAR) / Allow Natural

Death (AND) Comfort measures will always be provided


Part B: Medical Interventions

Patient/resident has pulse and/respirations

Comfort Measures Only: Medication by any route, positioning, wound care. Other measures to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway

obstruction as needed for comfort. Patient prefers no transfer: EMS contact medical control to

determine if transport indicated.




Limited Additional Interventions: Includes care listed above in comfort care. Medical treatment, IV fluids and cardiac monitor as indicated.

Do not use intubation or mechanical ventilation. Transfer if indicated, avoid ICU if possible.




Full Treatment and Interventions: All care in both sections above plus intubation and

cardioversion. Transfer to hospital if indicated. Includes intensive care.

Additional Orders: (e.g. dialysis, etc.) Use this section to state specific therapies, like dialysis and

blood transfusions and the goals or time limits for these.


Signatures

Statement of Intent: The signatures below verify that these orders are consistent

with the patient’s medical condition, known preferences and best known information. If signed by a surrogate, the patient must be decisionally incapacitated and the person signing is the legal surrogate.

Indicate who was involved in decision-making: Patient Parent of minor Guardian with Health Care Authority Spouse (or Domestic Partner. Indicate this) Health Care Agent (DPOAHC)


Signatures

Patient signature always preferred. If patient present but surrogate signing, note presence and

agreement of patient.

Surrogates for signing (Washington state): Guardian DPOA Spouse/Registered domestic partner Adult children Parent Adult sibling

Beyond that, there is no regulatory guidance. Consult ethics. Use team-decision making model with any family available.


Signatures

Physician (MD, DO) or Advanced Care Practitioner (ARNP or PA-C) must sign.

Verbal orders are acceptable with follow-up signature by physician, ARNP or PA in accordance with existing policies.

Signatures attest to the informed consent process having occurred.

Different health care settings designate/train different personnel for this purpose.

The POLST Form (Back)

Part D

Additional Patient Preferences (Optional) This includes antibiotics and nutrition therapy options. Formerly Parts C & D on front of form. Meant to guide therapies in non-emergent situations. Patient and provider signatures testify that conversation has

taken place.


Part D: Antibiotic Therapy

Antibiotics for infection: whatever the choice, notify physician of new infection

No antibiotics: use other measures to relieve symptoms. Determine use or limitation of antibiotics when infection occurs,

with comfort as goal. Use antibiotics with the goal of prolonging life.


Part D: Medically Assisted Nutrition

Artificially Administered Nutrition by parenteral or enteral route

No artificial nutrition by tube. Trial period of artificial nutrition by tube. (Goal: Write in how

long, till what event or goal is reached.) Long-term artificial nutrition by tube.

Always offer food and liquids by mouth if feasible. Additional orders:

Name specific goals of patient.


Directions for Health Care Professionals

Completing POLST Must be completed by health care professional.

Members of the health care team, RN, MSW, with proper training are well-positioned to have the appropriate conversations.

Should reflect the person’s current preferences and medical indications. Encourage completion of an advance directive. Advance directive should indicate congruent choices.

POLST must be signed by a physician (MD or DO)/ARNP/PA-C to be valid. Verbal orders are acceptable with follow-up signature per facility policy (see sample policies available at awphd.org or wsha.org).



Using POLST Any incomplete section of POLST implies full treatment for that

section. This POLST is effective across all settings including hospitals

until replaced by new physician’s orders. The health care professional should inquire about other

advance directives. In the event of a conflict, the most recently completed POLST form takes precedence.



Using POLST: SECTION A Patient has no pulse/no respirations No defibrillator (internal or external) should be used on a person

who has chosen “Do Not Attempt Resuscitation.”



Using POLST: 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).

An IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration with IV fluids may prolong life. A person who desires IV fluids should indicate “Limited Additional Interventions” (or “Full Treatment” if more aggressive care desired).



Using POLST: SECTION D Oral food and fluids must be offered if feasible.



Reviewing POLST: Review when:1) The person is transferred from one care setting or care level to

another, or

2) There is a substantial change in the person’s health status, or

3) The person’s treatment preferences change. A person with capacity, or the surrogate of a person without

capacity, can void the form and request alternative treatment. FORM CAN BE VOIDED; changes require new POLST. (Desire for

CPR and full treatment do not require POLST.)

POLST Resources

POLST Resources

Washington State Medical Association Provides POLST forms and information. Order at www.wsma.org/polst or call (206) 441-9762. For general POLST information contact: Graham

Short, WSMA associate director of communications, (206) 329-6851, [email protected].

Washington POLST Task Force Co-Chairs: Bruce Smith, MD: [email protected]. Sharmon Figenshaw, ARNP: [email protected].

POLST Skills Development - Sharmon Figenshaw and Bruce Smith

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