National Initiative Uses Medical Order Forms To Translate Patients’ End-of-Life Wishes Into Action
 Alvin Moss, MD, Director of the Center for Health Ethics and Law and Professor of Medicine at the Robert C. Byrd Health Sciences Center of West Virginia University |
 Amy Vandenbrouke, JD, Associate Director, OHSU Center for Ethics in Health Care and Chair, Oregon Physician Orders for Life-Sustaining Treatment Task Force |
 Susan Tolle, MD, Professor, General Internal Medicine and Geriatrics, School of Medicine and Adjunct Professor, Schools of Nursing and Dentistry, OHSU |
National Initiative Uses Medical Order Forms To Translate Patients’ End-of-Life Wishes Into Action
| By the Innovations Exchange Team Introduction: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm  is a national initiative designed to ensure that health care professionals across treatment settings honor the end-of-life treatment wishes of people who have advanced serious illnesses or who are frail. The national POLST office receives support from the Center for Ethics in Health Care at Oregon Health & Science University (OHSU). Forty-three States are in various stages of developing and implementing POLST programs. POLST goes by different names in different States, including MOLST (Medical Orders for Life-Sustaining Treatment), MOST (Medical Orders for Scope of Treatment), and POST (Physician Orders for Scope of Treatment).The Innovations Exchange interviewed members of the National POLST Paradigm Task Force: Alvin Moss, MD (Vice Chair), Susan Tolle, MD (Treasurer), and Amy Vandenbroucke, JD (Executive Director). Dr. Tolle and Dr. Moss have implemented POLST programs in Oregon and West Virginia, respectively. What was the impetus for creating the National POLST Paradigm? Susan Tolle, MD: The National POLST Paradigm originated in Oregon when a group of medical ethicists met in 1991. We realized that too many patients were being administered life-sustaining treatment against their wishes as a result of poor communication across all care settings. This included the intubation of long-term nursing home residents with dementia in the intensive care unit after admission to the hospital for pneumonia, and the administration of cardiopulmonary resuscitation (CPR) and other life-sustaining treatment to individuals in an emergency. (A short video about one patient, Max, offers an example). The OHSU Center for Health Care Ethics convened a task force to develop the first POLST form to translate end-of-life treatment wishes into medical orders. The Oregon task force released the form in 1995 and has engaged in ongoing education, research, and a statewide continuous quality improvement process to improve the content of the POLST form and the process of implementation.Did the Oregon paradigm spread to other States? Tolle: Other States, including New York, Pennsylvania, Washington, West Virginia, and Wisconsin, tailored the paradigm to fit their unique legal, medical, and cultural contexts. In 2004, the National POLST Paradigm Task Force (NPPTF) convened to establish quality standards for POLST Paradigm forms and programs and to help States develop such programs. How does POLST communicate a person’s wishes to health care professionals? Tolle: The POLST form translates patients’ treatment wishes and values into standing medical orders, which are recognized and honored by all health care professionals involved in a patient’s care, including emergency medical services (EMS) personnel. (Without POLST medical orders, EMS personnel are required to provide CPR and other life-sustaining medical interventions.) How does POLST compare with advance directives? Tolle: A major difference is that advance directives are appropriate for healthy individuals, while POLST is appropriate only for individuals who have advanced serious illnesses or who are frail. It is common for POLST-appropriate patients to die within a year of initiating the form. Amy Vandenbroucke, JD: Advance directives focus on the person’s general wishes about future medical care. In contrast, the POLST form focuses on the specific wishes of a patient with a diagnosed medical condition and known poor prognosis, in which the clinician would not be surprised if the patient died in the next year. As a result, the related end-of-life conversation with a health care professional is more specific and comprehensive. How does POLST compare with do-not-resuscitate orders? Tolle: The POLST form goes beyond asking about CPR. Individuals can choose among three treatment levels that range from the least aggressive to the most aggressive: comfort measures, limited additional interventions, or full treatment. Patients who choose comfort measures would be hospitalized only if those measures could not be provided in the patient’s current home environment. Patients who choose limited additional interventions may be hospitalized for antibiotics, intravenous fluids, and cardiac monitoring, but would avoid more aggressive life-sustaining treatment in the intensive care unit. Patients who choose full treatment may be hospitalized and treated more aggressively with life-sustaining treatment, including a ventilator in the intensive care unit. How does a POLST form become a medical order? Tolle: Patients, family members, or health care providers can initiate a conversation about a patient’s end-of-life wishes. Health care professionals should be trained to conduct shared decisionmaking discussions with patients and families so that POLST forms are completed properly. The POLST form addresses CPR, medical interventions, and artificial nutrition. Depending on State regulations, a physician, physician assistant, or nurse practitioner documents the patient’s wishes on the POLST form and signs it. The form is also signed by the patient or by the patient’s surrogate if the patient lacks capacity, and is included in the patient’s medical record. The patient is given the brightly colored original form to put on their refrigerator, where it can be easily seen by EMS personnel. Are POLST forms accessible electronically throughout the health care system? Alvin Moss, MD: The problem with paper POLST forms is that up to 25 percent of emergency medical technicians have reported difficulty finding the patient’s POLST form at the scene.1 Several States, including Oregon and West Virginia, have established electronic registries to ensure that the POLST form is available to any health care professional involved in the patient’s care. Tolle: When a POLST form is completed in Oregon, unless an individual chooses to opt out, the information is entered into the State registry, which is part of the statewide 911 system. Health care professionals and EMS personnel can call the statewide Emergency Communication Center and access the POLST form in less than 2 minutes. What care settings use POLST? Tolle: The program is built on a coordinated system of care across treatment settings, including EMS, hospitals, primary care practices, long-term care facilities, and home hospice. The initial conversation might occur in a hospital before a patient is discharged to a skilled nursing facility, in a primary care office when a patient with an advanced serious illness or frailty needs a higher level of care such as assisted living, or when a patient is admitted to a nursing home. Long-term care facilities, including assisted living facilities and nursing homes, are common users of POLST. The Oregon POLST pilot program began in 1995 in long-term care facilities. Today, all long-term care facilities in Oregon use POLST. Are POLST orders followed consistently in care settings? Tolle: A study published in 2011 involving 90 nursing homes in Oregon, West Virginia, and Wisconsin showed that POLST orders to provide or withhold life-sustaining treatment were consistent with the treatment provided residents 94 percent of the time. The exception was antibiotics, which were provided to 32 percent of residents with orders for no antibiotics; and feeding tubes, which were provided to 36 percent of residents with orders for no feeding tubes.2 A study published in 2009 of POLST use in hospice settings in Oregon, Wisconsin, and West Virginia found that a vast majority of hospice staff believed the POLST was useful in preventing unwanted resuscitation (97 percent) and in initiating conversations about treatment preferences (96 percent). Preferences for treatment limitations were respected in 98 percent of cases, and no one received unwanted CPR, intubation, intensive care, or feeding tubes.3 What role do nurses play in implementing State POLST programs? Tolle: It depends on the State. For the past decade in Oregon, nurse practitioners have been signing POLST forms; in California and West Virginia, only physicians sign POLST forms. As State programs mature, there is a movement to allow the patient’s primary care provider to initiate the POLST conversation and write the orders. We encourage more States to move in that direction. Our educational efforts are aimed at all POLST signers, including nurse practitioners, physician assistants, and physicians. How many States have implemented a POLST program? Vandenbroucke: The National POLST Paradigm has established national standards for States interested in using the POLST form and implementing a POLST program. Forty-three States are in various stages of gaining recognition as a POLST program. Twenty-four States are developing POLST programs, including two States (Massachusetts and Maryland) with POLST-like programs that deviate somewhat from the national standards and, as a result, have not been endorsed.4 An additional 16 States have statewide or regional programs that have been endorsed by the national POLST office. The endorsed programs have addressed the related legal and regulatory issues and have developed strategies for ongoing implementation and quality assurance. Included in the 16 States are Oregon and West Virginia, which have received “mature status” designation, which means that the POLST program is used by 50 percent or more of hospitals, nursing homes, and hospices in the State. States applying for mature status must indicate that they collect data for quality assurance programs. Although not a requirement for mature status, Oregon and West Virginia have developed centralized POLST databases to facilitate data collection for quality assurance.4 What training is provided by the national POLST office to States developing POLST programs? Vandenbroucke: The national POLST office hosts an annual conference to help health care professionals implement POLST programs in their States. We also look to States such as Oregon and West Virginia with mature status to gather materials for the national POLST Web site, so other States can adapt them to their own programs. It’s a very collaborative process. We also answer questions from States developing POLST programs, provide technical assistance and tools such as quality evaluations, and coordinate consultations with emergency departments, if needed. Moss: The national POLST office shared its resources and slides for presentations that it gave in West Virginia to convince health care groups to support POST (Physicians Orders for Scope of Treatment) legislation that was enacted in 2002. West Virginia was the first State to pass a law that provided legal protection to health care providers who honor POST orders signed by physicians who were not credentialed by their institutions. The National POLST Paradigm Task Force has encouraged States to obtain legal or regulatory protection for all patient care staff to honor POLST orders. What lessons have you learned from implementing POLST programs in your State? Tolle: We have learned that education never ends. Like any aspect of health care, there should be continuous quality improvement. For example, Oregon’s POLST form is in its eighth version, to incorporate revisions to better explain the health care options. We also learned to use new technology to share and retrieve the POLST form, such as the statewide electronic registry that now contains nearly 150,000 forms. We require all States seeking the POLST Paradigm endorsement to establish a periodic review of their POLST forms. Moss: We have revised West Virginia’s POST form six times based on feedback to our statewide ethics committee network from health care professionals and administrators. Changes have included adding a box for patients to authorize a legal surrogate to complete a new form based on their wishes if their condition deteriorates. We also added a box for patients to opt into the electronic registry by authorizing their health care providers to submit the form and the registry to release the form to treating health care providers. This process differs from the Oregon program, which mandates that all POLST forms be submitted to its registry unless patients choose to opt out. We have found that emergency physicians, rescue squads, and EMS personnel are enthusiastic about POST forms. They recognize that before POST forms were implemented, frail, elderly patients who were near death were subjected to CPR and other aggressive treatment that they didn’t want. About Susan Tolle, MD: Dr. Tolle is a Professor in the Department of General Internal Medicine and Geriatrics, School of Medicine, and an Adjunct Professor, Schools of Nursing and Dentistry, at OHSU. Dr. Tolle is also Director of the Center for Ethics in Health Care at OHSU and serves as Treasurer of the National POLST Paradigm Task Force. She was a founding member of the Oregon POLST Task Force, on which she continues to serve. About Alvin Moss, MD: Dr. Moss is Director of the Center for Health Ethics and Law and Professor of Medicine at the Robert C. Byrd Health Sciences Center of West Virginia University. He is Executive Director of the West Virginia Center for End-of-Life Care, and chaired the group that developed the clinical practice guideline Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. His research interests include dialysis ethics, advance care planning, and improving care at the end of life. He also serves as Vice Chair of the National POLST Paradigm Task Force. About Amy Vandenbroucke, JD: Ms. Vandenbroucke is Associate Director of OHSU's Center for Ethics in Health Care, and Chair of the Oregon POLST Task Force. She also serves as Executive Director of the National POLST Paradigm Task Force. Disclosure Statements: Dr. Tolle reported that the Center for Ethics in Health Care at OHSU received private gifts and grants through the OHSU Foundation. The OHSU Center for Ethics has current grants to specifically support the national POLST Paradigm initiative from The Retirement Research Foundation, the California HealthCare Foundation, and the Archstone Foundation. Ms. Vandenbroucke reported that the OHSU Center for Ethics in Health Care received private gifts and grants through the OHSU Foundation and OHSU. These private gifts and grants provided travel support for her to attend related conferences. The OHSU Center for Ethics has current grants to specifically support the national POLST Paradigm initiative from The Retirement Research Foundation, the California HealthCare Foundation, and the Archstone Foundation. Dr. Moss reported that West Virginia University received research grants from OHSU and travel support for him to attend a research planning meeting in Portland, Oregon. Dr. Moss also has current private grant support from the Claude Worthington Benedum Foundation. Footnotes
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