POLST’S Place in End-of-Life Planning: Turning Wishes into Action
Pennsylvania Orders for Life-Sustaining Treatment (POLST) is a process for implementing medical treatment decisions for persons nearing the end of life who have a serious and chronic illness. This process includes a medical form, available from the Pennsylvania Department of Health (Click here for POLST form), that can be used to convey as medical orders the decisions and preferences regarding the types and level of treatment that the person wants, or chooses to decline, as he or she nears the end of life.
Here are some common questions asked about POLST:
WHO SHOULD HAVE A POLST?
A POLST is intended for persons who have an advanced chronic progressive illness, are in an advanced chronic progressive state of frailty, or who have some other condition that may require life-sustaining medical treatment in the foreseeable future that they wish to forgo. For example, a POLST would be indicated for someone whose illness or state of frailty is advanced to the point that he or she would not benefit from cardiopulmonary resuscitation (“CPR”).
A POLST should not be used for someone who may have an early stage progressive illness or a condition that makes them functionally disabled, but who is nevertheless expected to survive at least one year, so that life-sustaining treatment would be beneficial.
I HAVE A LIVING WILL — WHY DO I NEED A POLST?
The short answer, given by the National POLST office, is that “The POLST form complements the Advance Directive and is not intended to replace it.”
Every adult ideally should have a Health Care Durable Power of Attorney and Health Care Treatment Instructions (Living Will), which can be combined in one document. See our Estate Planning Article on Lifetime Planning for more details.
But a living will is essentially a “wish list” — a statement of your intentions regarding the types of treatment that you decline, or the types you may want, if you later have an end-stage medical condition or are permanently unconscious.
There is always the risk that your living will may not be followed.
There is the risk, however, that your living will may not be followed. For instance, it may get misplaced when you are transferred from one medical facility to another, or hospital emergency room staff may start in on CPR or other aggressive forms of treatment due to a delay in obtaining your medical records, which contain your living will.
A POLST is meant to overcome these limitations. First, it is to be printed on heavy Pulsar Pink cardstock, so that it will be easily seen and identified. Second, the POLST will stay with you (for instance, kept in a prominent place at your residence) so that it will be with you when you arrive at a hospital emergency room. A POLST wallet card can also be used for this purpose.
Most importantly, the POLST contains a physician or other health care professional’s written orders for treatment that hospital personnel will be bound to obey. Converting your wishes, preferences, and values into concrete medical orders will better ensure that your intentions will be carried out.
WHO COMPLETES THE POLST FORM — THE PATIENT OR THE DOCTOR?
The answer is “both.” The medical orders for treatment as stated in the POLST should reflect the outcome of a discussion that took place between you (or your surrogate) and the health care professional, each of whom will then sign the POLST. Questions typically raised by or on behalf of the patient during this discussion include:
✔ What are my chances of recovery from my illness or condition?
✔ How much longer does someone in my condition normally live? (If it is more than one year, the POLST form should not be used.)
✔ Will opting to receive more aggressive types of medical treatment (e.g., intubation, advanced airway interventions, and mechanical ventilation) and being placed in an ICU if I need to be hospitalized, increase the length of my life to some meaningful extent? Or will it likely make no difference?
✔ Are there levels of medical treatment, or any specific types of treatment, that will cause me pain or discomfort? If so, will those burdens outweigh the benefits that such treatment might provide me?
✔ How can I best ensure that my values, treatment preferences, and belief in the sanctity of life will be respected by the medical personnel who may be treating me?
WHAT IF THE PERSON NEEDING A POLST IS INCOMPETENT TO SIGN?
If the person with a serious illness is deemed to lack the capacity to understand and appreciate the effect of a POLST, the form can still be completed by his or her health care agent or, in the absence of such an agent, by a health care representative. This surrogate could engage in the discussion with the health care professional and convey the person’s preferences and values regarding treatment choices, which can then be memorialized in the POLST form.
Avoiding Misuse of POLST. It is important that the POLST process not be misused by an agent, relative, or other third party who may be motivated to have a POLST used to prevent life-sustaining treatment for someone who may be weak and in poor health but is not likely to die within a year. Health care professionals who are asked to sign a POLST in such cases should decline to do so.
WHAT IS COVERED IN A POLST?
Four types of treatment are covered in the POLST, including the person’s preferences regarding the delivery of: (1) antibiotics and (2) nutrition – hydration. The other two treatment topics are:
Preferred Level of Medical Intervention
✔ The person may opt to have treatment limited only to comfort measures. In this case the physician’s order would direct that care is to be provided only to relieve pain and suffering, and that the person is not to be transferred to a hospital for life-sustaining treatment. A transfer would be permitted only if the person’s comfort needs cannot be met in the current location.
✔ In addition to treating pain and suffering, the physician’s order could also approve medical treatment, IV fluids, and a cardiac monitor as indicated. The patient could be transferred to a hospital, but if possible should not be placed in intensive care.
✔ The highest level of intervention the person (or surrogate) could choose would include the use of intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Likewise, the order would permit transfer to a hospital, including intensive care.
Cardiopulmonary Resuscitation (CPR)
Should CPR be given to the person if he or she is found to have no pulse and is not breathing? The POLST can order that medical personnel either:
✔ Start CPR and attempt resuscitation or
✔ Forgo resuscitation (DNR) and allow a natural death to occur.
DO I NEED BOTH A POLST AND AN OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER ?
Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Orders have been recognized in Pennsylvania since 2007. In fact, a complete form entitled “Pennsylvania Out-of-Hospital Do-Not-Resuscitate Oder” is contained in the Pennsylvania Probate Estates and Fiduciaries Code.
OOH-DNR Orders are focused exclusively on cardiopulmonary resuscitation (CPR) for patients who are in an end-stage medical condition or permanently unconscious (the same conditions that must be present to trigger the living will). By contrast, a POLST addresses several types of treatment choices, in addition to CPR, and applies to any patient who is at least “seriously ill” (i.e., not expected to live more than one year), which is a much lower bar to meet than “end-stage medical condition” or “permanently unconscious.”
Under current practice, it is only an OOH-DNR Order, not a POLST, that will be sufficient by itself to cause an EMS provider to forgo CPR. If the EMS provider is presented only with a POLST, he or she is required to first contact the EMS medical command physician to request a separate order allowing the POLST to be followed. The delay required by this additional step may cause EMS providers to perform CPR on the patient, even if the POLST would explicitly refuse it.
Thus, under current practice in Pennsylvania, for individuals whose medical condition indicates they are at risk for cardiac or respiratory arrest so that it is possible that an EMS provider will be called to their home or place of work, obtaining an OOH-DNR Order from their physician, along with an OOH-DNR bracelet and necklace, would be a prudent step.
The POLST represents an important development in the medical treatment of individuals who are nearing the end of life. The POLST is not intended to replace the living will; in fact, the two should work together, since the POLST will better ensure that the individual’s wishes and intentions as expressed in the living will will be carried out.
If Pennsylvania gives statutory approval to the POLST process, it will hopefully protect EMS providers who rely on orders contained in a POLST without having to first seek a separate order from a medical command physician. This change will put the POLST on the same level as an OOH-DNR Order, and in fact probably eliminate the need for the latter form.