Understanding POLST Is Good Practice
Emergency physician Michael Barton, MD, sings about the importance of understanding physician orders for life-sustaining treatment in his song “Good Practice.”
Explore This IssueACEP Now: Vol 34 – No 05 – May 2015
In the face of a quickly growing national POLST movement, we should perform more research as it relates to patient safety and provider understanding. Medical providers need to embrace POLST but be aware of its limitations. One should consider guidelines from the American Bar Association and National POLST Paradigm Task Force regarding reviewing and confirming choices elected on POLST forms.10 The use of a patient-safety checklist would be a conservative approach to individualize patient care and safety. A resuscitation pause or advance directive patient-safety checklist (see Table 1) represents an opportunity to maintain compliance with existing national recommendations and also help ensure the delivery of appropriate care.7,8,11,12
Dr. Mirarchi is medical director of the department of emergency medicine at UPMC Hamot and chair of the UPMC Hamot Physician Network in Erie, Pennsylvania.
Table 1. ABCDEs of the Living Will, DNR, or POLST13
Ask patients or surrogates to be clear as to their intentions for their advance directive (living will, DNR order, or POLST form).
Be clear as to if this is a terminal condition despite sound medical treatment or persistent vegetative state versus a treatable critical illness.
Communicate clearly if you feel the condition is reversible and treatable with a good or poor prognostic outcome.
Design a plan and discuss next steps. For example, say, “Your mom is critically ill. We can give her a trial of instituting life-sustaining care for 48 to 72 hours, and if there is no benefit, we can withdraw care and treatment.”
Explain that it’s OK to withhold care and treatment or withdraw care so long as it’s in keeping with the patients’ perceived wishes. Also, take a moment to explain the benefits of palliative care and hospice.
- Hickman SE, Nelson CA, Perrin NA, et al. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc. 2010;58:1241-1248.
- California Advocates for Nursing Home Reform. Physician orders for life sustaining treatment (“POLST”): problems and recommendations, 2010. Available at: http://www.canhr.org/reports/2010/POLST_WhitePaper.pdf. Accessed April 9, 2014.
- Fromme E, Zive D, Schmidt T, et al. Association between physician orders for life-sustaining treatment for scope of treatment and in-hospital death in Oregon. J Am Geriatr Soc. 2014;62(7):1246-1251.
- Richardson DK, Fromme E, Zive D, et al. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann Emerg Med. 2014;63:375-383.
- Schmidt TA, Zive D, Fromme EK, et al. Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST registry. Resuscitation. 2014;85:480-485.
- Nicholas LH, Langa KM, Iwashyna TJ. Regional variations in the association between advanced directives and end-of-life Medicare expenditures. JAMA. 2011;306:1447-1453.
- Mirarchi FL, Doshi AA, Zerkle SW. TRIAD VI–how well do emergency physicians understand physicians orders for life-sustaining treatment (POLST) forms? J Patient Safe. 2015;11:1-8.
- Mirarchi FL, Cammarata C, Zerkle SW. TRIAD VII–do prehospital providers understand physicians orders for life-sustaining treatment documents? J Patient Safe. 2015;1:9-17.
- Mirarchi FL, Costello E, Puller J, et al. TRIAD III: nationwide assessment of living wills and do not resuscitate orders. J Emerg Med. 2012;42:511-520.
- National POLST Paradigm Task Force. POLST legislative guide. Available at: http://www.polst.org/wp-content/uploads/2014/02/2014-02-20-POLST-Legislative-Guide-FINAL.pdf. Accessed May 16, 2014.
- Mirarchi FL. Avoid potential pitfalls of living wills, DNR, and POLST with checklists, standardization. ACEP Now. 2014;33:13.
- Mirarchi FL. A new nationwide patient safety concern related to living will, DNR orders and POLST-like documents. October 2014. Available at: http://www.npsf.org/blogpost/1158873/200782/A-New-Nationwide-Patient-Safety-Concern-Related-to-Living-Wills-DNR-Orders-and-POLST-Like-Documents. Accessed April 15, 2015.
- Mirarchi FL. Understanding Your Living Will. Omaha, Neb: Addicus Books; 2006.