When POLST forms conflict with prior advance directives, some states give precedence to the most recent form.
Explore This IssueACEP News: Vol 31 – No 09 – September 2012
According to OHSU’s POLST website, the National POLST Paradigm Task Force (NPPTF) has identified some required elements for developing such a program, including the presence of an established coalition and leadership, a standardized form, and the involvement of other stakeholders. Improving Advanced Illness Care: The Evolution of State POLST Programs, published by the AARP Public Policy Institute, describes how 12 states implemented their POLST programs.2
The POLST form (which can vary from state to state) has several sections with check boxes addressing various treatment options, such as resuscitation measures. Another section has check boxes for medical interventions, allowing the patient to choose among comfort care alone (including hospital transfer only if current institution is unable to provide such care), limited additional interventions (intubation, invasive ventilation), or full treatment.
Other sections address artificially administered nutrition/hydration (with options for none, a trial period, or long-term administration) and antibiotics (with options to not use, determine use when infection occurs, or use if medically indicated). Final sections include areas for documentation of the discussion, contact information for the patient (or decision maker) and health care provider, and signatures. The printed form usually is on brightly colored paper, often pink. Some states have “opt in” or “opt out” electronic registries and ePOLST options.
Some clinicians raise concerns that POLST forms are too prescriptive; however, one study showed there are 35 possible combinations of orders reflecting patient choices. Moreover, the study showed that clinicians honored POLST documents, with patients receiving requested treatments and avoiding treatments they did not endorse. Even though the study’s results reflect only one community’s experience in implementing a POLST program, they indicated that POLST forms are becoming more widely used.3
POLST orders are not portable from state to state because medicine is regulated at the state rather than federal level. Some state legislatures, however, have chosen to uphold the validity of signed out-of-state POLST forms; others have not, or remain silent on this issue.4
Unsigned forms are not valid, and forms with incomplete sections usually default to full treatment for that section. While emergency physicians cannot be familiar with all such nuances, in many situations they can accept POLST forms as communicating a patient’s wishes regarding end-of-life treatment. Ethically, and in most cases legally, physicians are protected as long as they act in good faith with what is believed to be the patient’s health care elections.