Florida POLST
physician orders for life-sustaining treatment

About POLST

Providers in Florida are familiar with the DNRO (the yellow) form. This order directs EMTs, hospital or nursing home personnel, and others not to attempt resuscitating a patient if he or she experiences a cardiopulmonary arrest. It is appropriately ordered when a patient expresses a desire to forgo CPR, or when it is clear that CPR would not provide benefits to the patient. The Physician Orders for Life-Sustaining Treatment (POLST) form goes beyond that to include orders for a level of medical interven-tions and whether and how artificial nutrition will be used. POLST was created to foster high-quality, patient-directed care across health care sites. Patients in the long-term-care (LTC) system are among the highest risk for experiencing transitions in care, and care being provided by multiple different providers. LTC providers nationally are among the best at providing advance care planning, since it is a fundamental part of our care. However, all too often we have seen how a deep and repeated conversation about the care plan is lost when our patients go to the hospital or another setting. Hence, the need for an effective method to communicate the patient’s wishes for medical interventions across sites of care is particularly important to us.

About the National POLST Paradigm

About the National POLST Paradigm (From National POLST Paradigm Website)

The National POLST Paradigm is an approach to end-of-life planning that helps elicit, document and honor patient treatment wishes. The POLST Paradigm emphasizes:

(i) advance care planning conversations between patients, health care professionals and loved ones;
(ii) shared decision-making between a patient and his/her health care professional about the treatment the patient would like to receive at the end of his/her life; and
(iii) ensuring patient wishes are honored.

As a result of these conversations, patient treatment wishes may be documented on a POLST Form, which translates the shared decisions into actionable medical orders. The POLST Form assures patients that health care professionals will provide only the treatments that patients themselves wish to receive, and not the treatments they wish to avoid.

The POLST Paradigm is not for everyone. Only patients with serious illness or frailty whose health care professional would not be surprised if they died within one year should have a POLST Form. For these patients, their current health status indicates the need for standing medical orders. Another way to look at it: patients appropriate for a POLST conversation are those who are most likely to have a medical crisis (predictable based on diagnosis) but who may not want our current standard of care, which is to do everything possible in an attempt to save someone’s life. A health care professional determines if a patient is appropriate for a POLST conversation. For healthy patients, an advance directive is an appropriate tool for making future end-of-life treatment wishes known.

The National POLST Paradigm embodies and promotes the essential elements of a POLST Paradigm Program; individual states and regions implement POLST programs. As a result, state programs vary in name (e.g. MOLST, MOST, and POST), how their programs are implemented, and in the appearance of their forms. Although these programs may be identified by the National POLST Paradigm Task Force (Task Force) as “Developing Programs” and use the term “POLST” or a similar term, they do not represent the POLST Paradigm until they have been endorsed by the Task Force. Only state programs that have demonstrated to the Task Force that their POLST Paradigm Program and Form meet Task Force standards can be endorsed. 23 states have Task Force endorsed programs, 23 states have developing programs, 1 state plus the District of Columbia are not yet considered developing, and 3 states have programs that don’t conform to National POLST Paradigm requirements.

To learn more please visit www.polst.org.

Advance Care Planning for the Seriously Ill

POLST – Advance Care Planning for the Seriously Ill (From National POLST Paradigm Website)

Advance care planning helps ensure patient treatment preferences are documented, regularly updated, and respected. There are two documents used to record these preferences: advance directives and Physicians Orders for Life-Sustaining Treatment (POLST) forms.1 These two documents differ in many ways; however, they can work together in approaching end-of-life planning.

This article addresses their differences and clarifies misconceptions about POLST and its relationship to advance directives.

Clarification of POLST Paradigm Program

The National POLST Paradigm Program Task Force (NPPTF) was convened to establish quality standards for POLST programs and to assist states in program development. The NPPTF endorses states adhering to POLST Program tenets; currently there are 162. Endorsement means: (i) the program and its form adhere to NPPTF standards; (ii) the program has addressed legal and regulatory issues associated with POLST and; (iii) the program has developed strategies for ongoing implementation and state-wide dissemination of the POLST program and quality assurance. States not endorsed may still use POLST terminology (or something similar) in developing their programs but they have not shown they meet the NPPTF’s established standards.

Advance Directives and POLST Forms

There are two types of advance directives, which can standalone or be combined: living wills and health care proxy3. Living wills identify types of treatment a patient wants or does not want if they are terminally ill or in a vegetative state and lack decision-making capacity. A health care proxy document identifies a surrogate to make decisions when the patient lacks decision-making capacity. All competent adults should be encouraged to have an advance directive.

POLST is not an advance directive but an actionable medical order, although not in the traditional sense. POLST is only for seriously ill patients for whom their health care professional (HCP) would not be surprised if they died in the next year. It would be inappropriate for a HCP to complete a POLST form for a patient who is outside the intended POLST patient population.

Complementary Documents

Neither form supplants the other; they complement each other. Most importantly, both encourage needed advance care planning conversations among loved ones to understand a patient’s goals of care and treatment preferences so they can be honored when the patient is unable to speak for him/herself. It is only through these ongoing conversations, and revisions of both documents as necessary, that either can ensure patient treatment desires are honored.

Both documents are only as good as the conversation and information shared prior to completing them. POLST creates the opportunity to have a more specific advance care planning conversation than is likely to occur with an advance directive.

POLST is not just a piece of paper but also the culmination of a shared decision-making process between the patient and his/her HCP. The HCP identifies and discusses the patient’s specific diagnosis, prognosis, and treatment options (including the benefits and burdens of each). The patient shares his/her values, beliefs and goals of care. Using all that information, the HCP and patient work together to make decisions about desired treatment. The HCP completes the POLST, documenting the decisions; it is only after this conversation that the HCP signs the POLST.

The advance directive not only identifies the surrogate to stand in the patient’s shoes when the patient lacks capacity but provides guidance for the surrogate and HCP on desired treatment. The longer patients, surrogates, loved ones and HCPs have engaged in advance care planning conversations, the more likely the parties will be able to ensure a patient’s wishes are identified and honored.

The POLST Paradigm Program requires HCPs to be trained in conducting shared decision-making discussions with patients and families so POLST forms are properly completed; states must show evidence of education to this point in order to be endorsed. The POLST Paradigm Program expects these conversation to occur and strongly recommends that all POLST forms require documentation affirming this conversation took place through documenting patient or surrogate signature, attestation or consent.

Similarities

Both are voluntary. Both document patient treatment preferences and goals of care; the living will captures this information, as does Section B of the POLST.

Key Differences

Unfortunately, confusion about these two documents persists, leading some individuals to consider only one of them while ignoring the potential benefit of the other. Clinical experience and research demonstrate that advance care directives are not sufficient to ensure that care goals of patients with serious advanced illnesses will be honored unless a POLST form is also completed.6
The salient differences between these documents are presented in the Table.

Completion of Document

Completion of an advance directive does not require assistance by a HCP; individuals can complete them on their own. Signatures required to make an advance directive valid vary by state but usually include the signature of the patient and a witness/es (some states require notarization of advance directive forms).  POLSTs are completed and signed by HCPs; states with POLST Programs provide on-going education to HCPs on how to properly complete POLST forms.

Language of Document

Advance directives generally have language that may not be understood by the general public and does not clearly define treatment options. Consequently, a patient’s advance directive may be vague and not easily interpreted. As a result, when reviewing an advance directive for treatment options, the HCP and surrogate may be required to speculate what the patient would have wanted in the specific medical circumstance.POLSTs have specific language about treatment options so they are easily interpreted and followed. POLST turns patient treatment preferences and goals of care documented in an advance directive into medical orders that may be followed in an emergency.

Timing of Document Completion

While both document future treatment preferences, advance directives can be completed at any time since they document general wishes for an unspecified future medical crisis. POLST documents specific wishes based on specific knowledge of a patient’s specific disease (and its progression). While the specifics of exactly what will happen as the disease progresses is unknown, the prognosis and understanding of the disease progression are known and the universe of possibilities is restricted.

Ease of Modification or Revocation

Modification or revocation of an advance directive usually requires compliance with state law or regulation, as well as obtaining new signatures from multiple individuals (see Signatures above). A key tenet of the POLST program is that POLST forms must be easily modified or revoked to allow patients to change treatment decisions as their disease progresses. Consequently, POLST forms are created to be easily modified or revoked.

Accountability

If the advance directive is poorly written, confusing, contradictory, or not signed by all required parties, it may be invalid or not followed without anyone being accountable for such errors. As a medical order, only those professionals with training should complete a POLST form with the patient or surrogate and, further, the HCP with authority to sign medical orders is responsible for reviewing the POLST prior to signing to ensure the orders are consistent with the decisions reached during the shared decision-making process. The signing HCP is accountable for the POLST orders.

Document Review During a Medical Crisis

In a medical crisis, emergency medical service (EMS) personnel institute cardiopulmonary resuscitation and other life support measures unless they have medical orders to the contrary. As medical orders, POLST forms are followed in times of crisis by EMS personnel in accordance with protocol, and by treating health care professionals, including physicians. Since a POLST form is brightly colored and included in a patient’s medical record, it is easily located. Advance directives are not medical orders so EMS personnel cannot follow them; instead, they are generally reviewed (if they can even be located) once the patient has been transported to the health care facility.

Final Comments on POLST

Some POLST opponents have stated that conversations with patients and their HCPs suffice for advance care planning, but conversation alone is not a viable alternative to a POLST. During emergencies, EMS personnel follow protocols. They cannot follow requests from surrogates, interpret advance directives, and they generally do not have time to identify and call the patient’s HCP to ask for orders.

The POLST form is patient-centered and honors patients’ moral and religious beliefs. For example, it allows Catholics to make decisions consistent with the United States Conference of Catholic Bishops Ethical and Religious Directives for Catholic Health Care Services, 5th ed. (2009) and ensures that those decisions will be honored in an emergency and across care transitions. The POLST form allows HCPs to work with the patient (or his/her surrogate) to order treatments the patient wants and to ensure that treatments the patient considers “extraordinary” and/or excessively burdensome not be provided. Further, the POLST form requires that “ordinary” measures to improve the patient’s comfort and food and fluid by mouth, as tolerated, always be provided.8

POLST recognizes that allowing natural death to occur is not the same as killing. Euthanasia is illegal in every state, and POLST forms do not allow for active euthanasia or physician-assisted suicide. In Oregon, where POLST was developed and where there exists an assisted suicide law, all Catholic health systems use and honor POLST forms but not the assisted suicide law.

Electronic Registry Upgrade

Electronic Registry Upgrade Helps Fosters Greater Compliance with Patient End-of Life 2017

An electronic upgrade has given health providers at Oregon Health & Science University Hospital greater access to patients’ end-of-life care wishes.

The recently implemented upgrade allows OHSU Hospital providers to electronically retrieve information from Oregon’s Physician Orders for Life-Sustaining Treatment registry.

Susan Tolle, M.D., director of the OHSU Center for Ethics in Health Care in Portland, says the innovation has boosted OHSU’s ability to provide the kinds of end-of-life care that patients want — and only what they want.

The upgrade is especially important for patients who cannot make their wishes known when they are brought to the hospital. “You may not know that the patient has a form in the registry,” says Tolle, who also is an internist and professor of medicine at OHSU. “The patient may be too ill to speak, and there may not yet be anyone with them who knows anything about them.”

Tolle is a founder of the POLST program, which was launched in the early 1990s. Back then, she recalls, it was not unusual for patients at the end of life to be given more intensive care than they wanted. “Information did not flow effectively from one setting to another for patients who were incapable of speaking for themselves,” she says.

In 2009, POLST was expanded into a statewide registry that providers could call. Going statewide improved the flow of information, but the system was limited by the preponderance of paper records, Tolle says.

“POLST worked great if emergency medical personnel were called and it was visible in the home,” Tolle says. “There were bright pink POLST forms on the refrigerator, or maybe the POLST magnet. But sometimes it couldn’t be found. You have to be paper and electronic at the same time for this system to work.”

An electronic version of POLST went live at OHSU in 2015, allowing automated submission of information into the state registry. The electronic system was developed by Vynca, a California-based provider of advance care planning solutions.

“Our system allows for these documents to be created in a completely digital format, legible and error-free, and that can be shared across care ecosystems,” says Ryan Van Wert, M.D., Vynca’s co-founder and chief medical officer.

In June, OHSU’s ePOLST system was upgraded to make it bidirectional, meaning OHSU Hospital providers can electronically access patient information housed in the statewide registry.

The upgrade serves a great need, Tolle says, noting that OHSU Hospital is a statewide trauma center and does not have records on all the patients for whom it cares.

“We now expect OHSU to get it right every time,” Tolle says. “We expect that if a patient does not want to go to intensive care, does not want to be intubated, that that will not happen. We’re almost all the way there now.”

Electronic access to a patien’s end-of-life wishes also is gaining traction at other health organizations. Samaritan Health Services, based in Corvallis, Ore., logged on to ePOLST early this year. Van Wert says Vynca is working with Samaritan to make its system bidirectional as well.

Tolle notes that the Oregon registry also can partner with other technology providers to attain such upgrades. “We’re continuing to push out information,” she says.”

FMDA – Moving POLST Forward in Florida

May 2017 Progress Report

FMDA – Moving POLST Forward in Florida by Kenneth Brummel-Smith, MD, Professor Emeritus, Department of Geriatrics, Florida State University College of Medicine

Advance care planning (ACP) is getting increased attention throughout our nation. New concepts have evolved – that ACP is a process, not just the signing of forms, and that people at different stages of life need different aspects of ACP. For our patients, moving from a general expression of wishes (such as a living will and appointment of a surrogate decision-maker) to a specific set of medical orders (such as a DNRO or the POLST) is desired by patients and necessary for providing effective medical care.

Advance directives are documents created by patients. Individual documents, such as the Florida Living Will, can serve as a general guideline as to how the patient wants to approach difficult medical decisions in the future. Similarly, the appointment of a health care surrogate can stipulate who the patient wants to speak for them medically if the patient cannot speak for him or herself. Comprehensive documents, like the 5-Wishes form or the Empath Choices form, combine these two decisions into one form. Ideally, all adults should consider completing these documents.

Orders to direct care near the end of life are not advance directives. They should be used in patients near the end of life or who have advanced frailty. It is in this stage of life when the patient may have clear wishes to avoid certain kinds of care, or when the burdens of certain types of care may outweigh the benefits. They, unlike advance directives, are not completed by patients. They must be completed and signed by a physician (and some states an NP or PA). Once the order is signed by the provider and the patient, they are used to direct care from then on. The patient (or surrogate if appropriate) can ask the provider to change the orders at any time. But the key difference between them and an advance directive is that other health care providers, such as EMTs and hospital personnel, can use them to guide their medical interventions.

Providers in Florida are familiar with the DNRO (the yellow) form. This order directs EMTs, hospital or nursing home personnel, and others not attempt resuscitating a patient if he or she experiences a cardiopulmonary arrest. It is appropriately ordered when a patient expresses a desire to forgo CPR, or when it is clear that CPR would not provide benefits to the patient. The Physician Orders for Life-Sustaining Treatment (POLST) form goes beyond that to include orders for a level of medical interventions and whether and how artificial nutrition will be used.

POLST was created to foster high-quality, patient-directed care across health care sites. Patients in long-term-care (LTC) system are among the highest risk for experiencing transitions in care, and care being provided by multiple different providers. LTC  providers nationally are among the best at providing advance care planning, since it is a fundamental part of our care. However, all too often we have seen how a deep and repeated conversation about the care plan is lost when our patients go to the hospital or another setting. Hence, the need for an effective method to communicate the patient’s wishes for medical intervention across sites of care is particularly important to us.

FQAC Strategic Forum Videos

FMDA’s Quality Advocacy Coalition Strategic Forum: The Impact of End-of-Life Care & Advance Directives on Hospital Re-admissions (Videos #1-13)

Held Thursday, Oct. 12, 2017 * Disney’s Grand Floridian Resort

The Strategic Forum was hosted by FMDA – The Florida Society for Post-Acute and Long-Term Care Medicine in collaboration with Florida Hospital Association, Health Services Advisory Group (QIO/QIN), Agency for Health Care Administration, Florida Health Care Association, and Florida College of Emergency Physicians.

The follow 13 videos cover the meeting topics and speakers in chronological

Order as shown below. Each video runs approximately 17 minutes.

Video 1

Welcome remarks and purpose of FQAC and the Strategic Forum
Co-Chairs Dr. Steven Selznick and Dr. Rick Foley

FMDA Welcome: Defining the Challenges — Leonard Hock, DO, MACOI, CMD, HMDC, FAAHPM; President

Presentations with questions and answer periods

Palliative Care – Leonard Hock, DO, MACOI, CMD, HMDC, FAAHPM; Chief Medical Officer, Harbor Palliative Care & AIM, TrustBridge Health; President, FMDA

Video 2

Video 3

Impact of End-of-Life Planning on Preventing Avoidable Hospital Readmissions – Edna Clifton, Director of Care Coordination, HSAG; and Amy Osborn, NHA, PMP, Executive Director, HSAG

Video 4

Legal Aspects of Advance Directives – Karen Goldsmith, Esq.; Regulatory Counsel, Florida Health Care Association

Video 5

Video 6

The Impact of Advance Directives on EMS – Joe A. Nelson, DO, MS, FACOEP-D, FACEP; State EMS Medical Director, Florida Dept. of Health

Video 7

Advance Directives and the Nursing Home Perspective – Deborah K. Franklin, NHA; Senior Director of Quality Affairs, Florida Health Care Association

Video 8

Video 9

Physician Orders for Life Sustaining Treatment: An Overview – Niharika Suchak, MBBS, MHS, FACP, AGSF; Associate Professor, Department of Geriatrics, Florida State University College of Medicine

Video 10

Being Engaged About the Value of POLST – Benjamin Kaplan, MD, MPH, FACP; Internal Medicine Faculty, Orlando Regional Medical Center; Internal Medicine Clerkship Director and Clinical Assistant Professor, Florida State University College of Medicine, Orlando Campus

Video 11

Learn About a New Statewide Initiative to Increase Advance Care Planning in Florida – Kim Streit, MBA, MHS, FACHE; Vice President/Healthcare Research and Information, Florida Hospital Association

Video 12

Learn About a New Statewide Initiative to Increase Advance Care Planning in Florida – Kim Streit, MBA, MHS, FACHE; Vice President/Healthcare Research and Information, Florida Hospital Association
General Discussion, Thank You, and Closing Remarks

Video 13

POLST Paradigm Fundamentals

POLST Paradigm Fundamentals (From National POLST Paradigm Website)

1. A POLST Paradigm Form is not an advance directive, but it is an advance care planning tool. An advance directive is a mechanism for naming a health care agent or durable power of attorney for health care and providing general treatment wishes. A POLST Paradigm Form is a portable, actionable medical order that helps ensure patient treatment wishes are known and honored and helps prevent initiation of unwanted, disproportionately burdensome extraordinary treatment.

2. The POLST Paradigm is voluntary- it should never be mandatory to complete a POLST Paradigm Form.

3. It is imperative to the POLST Paradigm that the process of completing a POLST Paradigm Form involve informed, shared decision-making between patients and health care professionals. The conversation involves the patient discussing his/her values, beliefs and goals for care, and the health care professional presents the patient’s diagnosis, prognosis, and treatment alternatives, including the benefits and burdens of life-sustaining treatment. Together they reach an informed decision about desired treatment, based on the patient’s values, beliefs and goals for care.

4. The POLST Paradigm is not for everyone; only patients with serious illnesses or frailty for whom their health care professionals would not be surprised if they died within a year should have a POLST Paradigm Form. For these patients, their current health status indicates the need for standing medical orders for emergent or future medical care. For healthy patients, an advance directive is an appropriate tool for making future end-of-life care wishes known to loved ones.

5. A POLST Paradigm Form allows patients to have their religious values respected. For example, the POLST Paradigm Form allows Catholics to make decisions consistent with the United States Conference of Catholic Bishops Ethical and Religious Directives for Catholic Health Care Services, 5 ed. (2009) and ensures that those decisions will be honored in an emergency and across care transitions.

6. A POLST Paradigm Form enables health care professionals to order treatments patients would want during a medical crisis, helping avoid the provision of treatments patients would not want, such as those that the patient considers “extraordinary” and excessively burdensome.

7. A POLST Paradigm Form requires that “ordinary” measures to improve the patient’s comfort, and food and fluid by mouth as tolerated, always be provided.

8. State law authorizes certain health care professionals to sign medical orders; the POLST Form is signed by those health care professionals who are accountable for the medical orders.

9. A POLST Paradigm requires health care professionals be trained to conduct informed shared decision-making discussions with patients and families so that POLST Paradigm Forms are completed properly.

10. A POLST Paradigm Form may be signed by the patient or designated decision-maker (HCA, DPOA for Healthcare, or surrogate), but this is not required in all states. The National POLST Paradigm Task Force encourages patient or surrogate signatures (or witnessed verbal consent) be required on POLST Paradigm Forms.

11. The POLST Paradigm is not about how you want to die, it is about how you want to live with the time you have left.

12. The National POLST Paradigm recognizes that allowing natural death to occur is not the same as killing.

Religion and Advance Directives

Religion and Advance Directives

POLST Form

You may access the POLST Form by clicking here.