Physician Orders for Life-Sustaining Treatment
POLST stands for Physician Orders for Life-Sustaining Treatment. It is a medical order in the United States that relays a patient’s wishes for their end-of-life care with a physician’s approval based on previous medical examination. Doctors sign the POLST form when it is likely enough that the patient will die within one year and when the preferences are in line with the patient’s needs, as determined by a discussion between doctor and patient beforehand. Once signed, doctors and first responders (e.g. hospitals, emergency rooms, nursing homes, paramedics, police, and fire departments) will heed the POLST form in determining a patient’s treatment.
The Oregon POLST Task Force started in 1991, leading to the National POLST Paradigm in 2004. 42 states currently recognize the POLST, with a variation on whether the patient legally must sign and alternative names for the POLST programs. As a relatively new physician order, the POLST notably differs from advance directives –previously the only means of communicating patient preferences, and not a physician order. An advance directive can designate a surrogate to work with the patient’s care providers, but would not protect them from unwanted hospital transfers, CPR, and other emergency services that first responders must perform by law. The patient would have to sign a separate Do Not Resuscitate (DNR) order. Conversely, the POLST allows patients to set certain conditions for their emergency care but does not designate surrogates.
If you or a loved one require end-of-life care or expect to in the near future, consider obtaining a POLST form. This article will detail the various treatment options the POLST covers and the process of acquiring a valid form.
Why You Should Consider the POLST: Treatment Options
The main benefit of the POLST is its introduction of more choices than advance directives typically allow. Its wide array of treatment options appear in its four separate sections: CPR, Medical Interventions, Antibiotics, and Artificially Administered Nutrition. The options are as follows:
- CPR: A choice between CPR (“Full Treatment”) and a built-in DNR order (“Allow Natural Death”)
- Medical Interventions: The option to employ “Comfort Measures Only”, “Limited Additional Interventions”, or “Full Treatment” in the area of medical interventions
- Antibiotics: The determination of if and/or when care providers should use antibiotics
- Artificially Administered Nutrition: a choice between no artificial feeding, short-term artificial feeding, and long-term artificial feeding
In other words, treatment options from the POLST run a full spectrum from providing only care that reduces pain and suffering to provide full treatment. Unlike the usual DNR order, the CPR section’s “Allow Natural Death” option applies to patients breathing, responsive, or with a pulse instead of only applying to patients without these life signs. It also allows patients to choose limited intervention without transfer to the intensive care unit (ICU), a middle ground between full treatment and comfort measures only. The National POLST Paradigm reports that “approximately half of the patients who complete a POLST form in Oregon indicating that they do not want CPR also show that they want full treatment or limited interventions”, whereas first responders usually interpret a DNR order as comfort measures only.
Indeed, the Medical Interventions section covers the same spectrum. Its “Limited Additional Interventions” option includes intravenous (IV) fluids and antibiotics in addition to comfort measures at home, as well as the choice to avoid hospital transfers. “Full Treatment” involves all of the above with necessary hospital transfers. This section and the following two let patients select which IV fluids, antibiotics, breathing apparatuses, and feeding apparatuses to use. Feeding apparatuses include short-term nasogastric tubes and long-term gastric tubes, the short-term treatment leading to either no more treatment or long-term treatment based on the patient’s choice.
Despite these advantages, it is best not to see the POLST as an alternative to advance directives; the POLST does not designate you a surrogate, which is the reason why most doctors recommend advance directives. Surrogates are legally allowed to fill in the POLST in place of patients unable to make their own medical decisions. This brings us to the next section of this article, a guide on how to validate and manage a POLST form.
How to Obtain a Valid POLST Form
As mentioned, only patients at significant risk of death within one year can be considered eligible for the POLST. Such patients may be terminally ill, receiving hospice or palliative care, suffering from end-stage or metastatic organ disease, or living in a long-term care facility. Like any other major medical decision, it is up to you whether or not you obtain a POLST form; you should not feel pressured into it, least of all if you have no preferences or aversions to certain forms of care. With all of this in mind, here are steps to take if you decide the POLST is the right option.
All it takes to obtain a valid POLST form is a discussion between yourself or a surrogate and your doctor, concluding with the signage. This discussion will cover your diagnosis, prognosis, treatment options, and desired goals for the care. The physical POLST form is brightly colored and kept at the front of medical records or in the patient’s possession if they live in the community; health care professionals recommend keeping it with you in every new setting and in a place where emergency responders can access it.
If the patient, their surrogate, or a health care professional wants to void any part of the POLST form, up to and including the form in its entirety, they need only cross out the voided sections and add the word “VOID” in large text. Patients must inform their health care professionals know they have done this, and the professionals must let the registry know they have done this. Officials can also disregard ineffective or inauthentic forms. Otherwise, the patient has as many options to uphold, redo, or opt out of the form as the form has options for treatment.
The National POLST Paradigm summarizes their program as “helping people live the way they want until they die”. The element of choice the POLST provides can make a world of difference for a patient’s comfort levels in their final days of life.
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