When faced with a critical decision involving life or death, when minutes count, when there is little to no patient information available and potentially no one around to help us decide, emergency physicians can use the principles embodied in the POLST Paradigm Program and the patient’s wishes documented on the pink form to do what the patient would want at such a time. Acknowledging that the patient knows best, and that the decision matters most to that individual, steers a conscientious course.

Case resolution: Unless there is a good reason to think that the POLST form is not valid, the patient should not be intubated. She has a terminal illness and is at the end of life. Atropine, morphine, suction, and warm blankets are reasonable comfort measures. (Acknowledgment: ACEP Ethics Committee.)

References

1. Iserson KV. A simplified prehospital advance directive law: Arizona’s approach. Ann. Emerg. Med. 1993;22:1703-10.
2. Sabatino CP, Karp N. 2011. Improving Advanced Illness Care: The Evolution of State POLST Programs. AARP Public Policy Institute. Washington, D.C.: AARP (assets.aarp.org/rgcenter/ppi/cons-prot/POLST-Report-04-11.pdf; accessed May 21, 2012).
3. Hammes BJ, Rooney BL, Goondrum JD. A comparative, retrospective observational study of the prevalence, availability, and specificity of advance care plans in a county that implemented an advance care planning microsystem. J. Am. Geriatr. Soc. 2010;58:1249-55.
4. Hickman SE, Sabatino CP, Moss AH, Nester JW. The POLST (Physician Orders for Life Sustaining Treatment) paradigm to improve end-of-life care: Potential state barriers to implementation. J. Law Med. Ethics 2008;36:119-40.

Dr. Limehouse is an Assistant Professor of Emergency Medicine at Medical University of South Carolina, Charleston. Dr. Henrichs is an emergency physician and Deputy Medical Director at Pardee UNC Healthcare, Hendersonville, N.C. Dr. Geiderman is the Emergency Department Co-Chair at Cedars-Sinai Medical Center, Los Angeles.