Case: A 55-year-old woman with metastatic ovarian cancer is brought into your emergency department from home, unaccompanied, because of difficulty breathing and thick secretions that cannot be suctioned well. She is now unconscious, and her vital signs are BP 80/40; P115; RR 28; T 38C; spO2 85%. The medics show you a bright pink “physician order” form instructing you to provide comfort measures only. A physician – who is not on your medical staff but is from your state in a city 300 miles away – signed this fully executed form. Is this a valid order for you to follow, or should you intubate the patient?
Explore This IssueACEP News: Vol 31 – No 09 – September 2012
The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program provides comprehensive, portable end-of-life physician orders that convey a patient’s wishes regarding life-sustaining treatment and resuscitation.
Starting with Oregon in 1991, more than 40 states have adopted these orders in various forms using various acronyms: POLST in Oregon and California, POST (Physician Orders for Scope of Treatment) in West Virginia, MOST (Medical Orders for Scope of Treatment) in North Carolina, MOLST (Medical Orders for Life-Sustaining Treatment) in New York, and others. These forms differ from other advance directives such as living wills in that they are physician orders enabled by state statutes or regulations, they are accepted by emergency medical services, and they are not hospital specific.
More thorough than a simple do not resuscitate or do not attempt resuscitation (DNR/DNAR) order, the POLST or similar form allows for decision making by the patient regarding resuscitation, hospital transfer, comfort measures, antibiotic use (in some states), and hydration and nutrition.
As described on the Oregon Health and Science University’s POLST Paradigm Program website (www.ohsu.edu/polst), a POLST form permits effective communication of patient wishes and documentation of medical orders, and carries an expectation that health care professionals will carefully follow these wishes.
Clinicians use POLST forms and similar orders for advance care planning for patients with progressive illnesses and a prognosis of less than 1 year of life expectancy.
Grounded within the ethical principle of autonomy, the patient (or designated decision maker) and a health care professional discuss the benefits and burdens of life-sustaining treatment so that the patient can make his or her wishes known regarding such treatment. These discussions should occur when there is sufficient time to cover the issues fully, not when the patient is in extremis.
The POLST form supplements (but does not supplant) other advance directives. While statutory advance directives require witnesses and often notarization, POLST forms only require the signatures of the patient (or appropriate surrogate) and a clinician to be valid. Physicians must sign the form in some states, while midlevel providers may sign the form in others. Arizona has no POLST program but permits patients, rather than physicians, to initiate and validate a prehospital advance directive without the signature of a physician or other health care provider.1