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?

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

When POLST forms conflict with prior advance directives, some states give precedence to the most recent form.

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.

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.