Executive Summary

Clinicians at Oregon Health & Science University can immediately access patients’ Physician Orders for Life-Sustaining Treatment (POLST) forms with the newly launched ePOLST, a fully integrated electronic version of the POLST form.

  • Patient wishes are sometimes ignored because providers can’t access POLST forms.
  • Creating an ePOLST system is a significant IT investment.
  • Health systems can create integrated EMR systems internally to link to POLST forms.

Even if patients’ end-of-life wishes are meticulously documented using a Physician Orders for Life-Sustaining Treatment (POLST) form, they sometimes are ignored simply because a provider can’t locate the form.

“Patients and family expect that if they have completed POLST forms with their clinician, whether in a nursing home, clinic, or home hospice setting, that their wishes will be honored,” says Susan W. Tolle, MD, director of the Oregon Health & Science University (OHSU)’s Center for Ethics in Health Care in Portland. Tolle is chair of the Oregon POLST Task Force and a leader behind the original development of the POLST program.

In reality, says Tolle, “there are problems with electronic systems that are not integrated across different systems of care.” Using the newly launched ePOLST, a fully integrated electronic version of the POLST form, OHSU clinicians can immediately view the patient’s POLST form. “This is a next step in assuring the treatment preferences of those with advanced illness are elicited, recorded, and honored,” says Tolle.

The current statewide error rate for paper POLST forms submitted to the Oregon POLST registry is 18%. POLST forms are sometimes undated, or the patient or provider’s name is illegible. “ePOLST has taken us to a new place of reducing technical completion errors to zero,” reports Tolle. (To view OHSU’s POLST: Doing it Better” instructional video, visit http://bit.ly/1Lmyz7W.)

Just one click needed

The national POLST Paradigm Task Force recommends that a patient’s POLST form be available within one click in the electronic medical record. “This means that those caring for a patient in a crisis can see that a patient has a POLST form, with a ‘yes/no’ tab on the patient header,” says Tolle. Providers can click just once on “yes” without having to search anywhere else in the record, and view a scanned copy of the patient’s most recent POLST form.

“Even without the added benefits of the ePOLST system, ethics leaders should encourage their health system to develop electronic record systems, to be able to find POLST forms in a single click,” says Tolle.

Creating an ePOLST system is a significant IT investment, however. Alternatively, hospitals can create their own integrated systems that link all POLST forms completed in their inpatient and outpatient settings.

“This is the low-budget option that everyone can do,” says Tolle. “This is not hard to fix, and all ethics leaders should be pushing for this.”

Two tabs are created on the patient header that link to a “yes/no” indicator. “It is very important to keep POLST orders in a separate tab from advance directive forms,” notes Tolle. “Medical orders need to be found in seconds.”

More than 5,000 healthcare professionals have called the Oregon POLST registry seeking POLST forms urgently; 2,000 of those patients had POLST forms. “While providers can contact the POLST registry to get the information, the new ePOLST system is faster,” says Tolle.

Currently, 18 states have endorsed POLST programs, with many more in development. “Most states are moving toward a POLST paradigm because of its effectiveness,” says Tolle. Of 58,000 records of natural deaths in Oregon in 2010 and 2011 examined by researchers, nearly 18,000 had a POLST form in the Oregon registry. Only 6.4% of patients with “comfort measures only” orders on their POLST died in a hospital.1

“Knowing the POLST scope of treatment orders are strongly associated with the care patients ultimately receive increases our ethical obligation to be able to locate POLST forms within our health systems,” says Tolle.

Currently, OHSU clinicians are pilot-testing the ability to electronically search the Oregon POLST registry through ePOLST. This will make it easier to find POLST forms from other healthcare systems.

When OHSU converted to ePOLST in April 2015, 10,000 POLST forms were loaded into the system. “Ever since we went live with this, we stopped automatically intubating patients whose POLST form said ‘comfort measures only,’” says Tolle.

In the initial 3-month period of implementation at OHSU, the ePOLST button was clicked more than 6,000 times. “Because they can find it so easily, the internist, the attending, the ED nurse are all checking it,” says Tolle.

This means that providers aren’t starting from scratch with code discussions; instead, they can begin by stating something like, “I see that two weeks ago you completed a POLST form with your primary care physician. Would you like us to honor the wishes you’ve recorded on that form?”

“This is very different from saying, ‘If your heart stops, do you want us to start it?’ as if no conversation had ever happened before,” says Tolle. “It lifts a burden from families by not having to start again from the beginning.”

A month before ePOLST was implemented, a patient with advanced heart and lung disease was brought to OHSU in pulmonary edema, unable to speak for herself. She was being cared for at home and had completed a POLST form signed by her primary care physician, stating “comfort measures only.”

“Only the hired caregiver was with her, and she didn’t know if the patient had a POLST form,” says Tolle. The hospital’s EMR didn’t have the form because it was completed by a physician at a different health system. “She ended up being intubated in our ICU, with family saying, ‘What on earth are you doing?’” recalls Tolle. “Palliative care was consulted; later that day, she was extubated and died peacefully that night.” The family insisted that clinicians should have been able to find the POLST form, and that their loved one should not have been intubated.

Tolle recommends that bioethicists learn the details of similar cases occurring at their institutions. “Ask the ICU team when they have looked into the eyes of a family member who said, ‘Why did you do this? She never wanted this. Here’s the documentation and why couldn’t you find it?’” she says.

Each time this has happened in recent years, OHSU has made the case the focus of a morbidity and mortality conference. “Whenever one happens, do it again. Just keep having these conferences for your egregious cases,” says Tolle.

Tolle raised the issue repeatedly with OHSU’s IT department, president, and medical director before leaders agreed to launch ePOLST. “Don’t take ‘no’ or ‘later’ for an answer,” she says. “We have an ethical obligation to consistently find POLST orders.”

REFERENCE

  1. Fromme EK, Zive D, Schmidt TA, et al. Association between physician orders for life-sustaining treatment for scope of treatment and in-hospital death in Oregon. J Am Geriatr Soc 2014; 62(7):1246-1251.

SOURCES

  • Susan W. Tolle, MD, FACP, Director, Center for Ethics in Health Care, Oregon Health & Sciences University, Portland. Phone: (503) 494-4466. Fax: (503) 494-1260. Email: tolles@ohsu.edu.