Put it in pink if you want it to be followed

Form helps patients avoid unwanted treatments

In Oregon, a specially designed bright pink form has proven effective in ensuring the communication of and health care professionals’ adherence to dying patients’ wishes regarding medical treatment.

First conceived as a device that would enable emergency medical service (EMS) first responders to accommodate a patient’s desire to avoid resuscitative efforts, the Physician Orders for Life-Sustaining Treatment (POLST) has become a document that enables patients and their physicians to dictate specifically the care the patient will receive — for example, allowing comfort measures but not life-prolonging ones.

"POLST has become not just about what the patient does not want done, but has become more focused on comfort issues, ensuring that the patient’s needs in that area are addressed and we don’t just leave them hanging," says Susan Tolle, MD, director of the Center for Ethics in Health Care at Oregon Health Sciences University in Portland, which administers the POLST program.

The form, signed by a physician and indicating what types of medical interventions are allowed and disallowed, is placed in the patient’s chart. This form is recognized by EMS providers, physicians, hospitals, and hospice workers in every region of the state, Tolle says.

A recent study of the POLST document’s effectiveness, published in September’s Journal of the American Geriatrics Society, found that of 180 nursing home patients who had marked "Do Not Resuscitate" or "Transfer for Comfort Measures Only" on the form, none received cardiopulmonary resuscitation, intensive care unit admission, or ventilator support.1

"That shows that the form was not lost, overlooked, or ignored," Tolle explains. "That was what we were hoping to find."

The document had its genesis in 1990 at a statewide meeting of health care professionals gathered to address ethical concerns in medicine, says Patrick M. Dunn, MD, senior scholar at the Center for Ethics in Health Care and chairman of the POLST task force.

"At one of the meetings here in Portland, individuals from long-term care facilities presented the case of a man who was transferred from long-term care to a hospital for medical interventions that ended up, in retrospect, to be against the patient’s wishes," he explains. "This happened even though the patient had an advance directive."

The case resonated with many of the providers at the meeting, Dunn adds. "They were saying, Yeah, yeah, this is a problem for us. We receive these patients that have wishes that aren’t written down accurately.’"

Form isn’t just for directives

The coalition formed a task force of five working groups in Oregon to develop a form for documentation of a patient’s wishes that would be recognized and honored across different treatment settings. The distinction between the form it developed and an advance directive is an important one, Dunn says. "Advance directives are a method by which the patient can express their values and write them down for all to see. The POLST form is a set of physician orders that take the patient values and match them with medical indications for specific life-sustaining treatments. They kind of merge those indications and treatments together to embody the patient’s wishes."

EMS, for example, cannot act on an advance directive, Dunn says. In many cases in the past, EMS providers would respond to a call and begin the intervention called for in the protocol. At the same time, they would try to contact the patient’s attending physician or the physician supervisor for their cachement area of EMS for instructions on how to implement the advance directive, he explains. "The POLST gives that in advance."

The current POLST form is two-sided and hot pink. On the front, there are five sections labeled A, B, C, D, and E. (See form, inserted in this issue.) The first four sections cover different treatment categories: resuscitation, medical interventions, antibiotics, and artificially administered fluids and nutrition.

In each category, the medical indications for each treatment and which treatments are allowed are detailed. The last section, E, lists who the physician obtained the directive from (such as the patient, a health care representative, court-appointed guardian, spouse) and what the basis for the orders is. The back of the form, sections F and G, outlines procedures for changing the form and directs providers to any sources of additional information such as an advance directive or court-appointed guardian.

The form has undergone several changes, Dunn says. "Initially, it was called the Medical Treatment Cover Sheet. At first, it initially contained standards regarding cardiopulmonary resuscitation. As we learned from our EMS colleagues, the issues are really more complicated than that. . . . a simple DNR order, as clean as it may be, doesn’t address the majority of circumstances they respond to."

Since the form has expanded to cover many different treatment options and situations, its benefits have extended beyond what its developers had envisioned. "If I am covering for one of my colleagues, and I get called to a nursing home about a patient who has a POLST form indicating their wishes with respect to different kinds of treatment, then that can be very helpful to me," Dunn explains.

Supportive environment necessary

The POLST form is designed to function in Oregon’s "climate," Tolle adds. "I don’t think that you can just take this form and drop it into any situation in any state."

As the task force developed the form, it conducted a coordinated education effort, particularly among emergency medical providers, she emphasizes. "We wanted them to know what the form was, what it looked like. We didn’t want to have the form, then have them see it later and wonder, What is this?’"

Oregon also is unique in that its citizens have ready access to well-coordinated hospice care, and state laws are conducive to allowing patients to refuse medical treatment, she says. "This is one of the few places where, if someone needs a hospital bed in the home, I can make a call and get it there by sundown," Tolle says.

This support for medical care, particularly end-of-life care, outside the hospital setting, enables POLST to work so well, she adds.

That’s not to say that some far-reaching changes did not have to be made in the process of implementing the program, Dunn says. "We had to go to the board of medical examiners who make the administrative rules of practice for first responders," he explains. "We had to work with them to adjust the scope of practice regulations, to ensure that EMS would be obliged to honor valid orders, either on a POLST or like document."

At the Center for Ethics, they refer to the POLST "program" rather than the POLST "form" because the document is in a continual evaluation process. Designated resource consultants who have been specially trained are located at medical centers across the state. Over the course of about six months, they collect information on the use of the document in their area.

That information is sent to the Center for Ethics and then presented to the task force, which continues to meet on a semi-annual basis. "Key issues are collected, and when we meet, we take up those issues," Dunn says. "We have this constant feedback regarding the form."

For example, providers in the southern part of the state expressed a desire to develop a brochure for the layperson explaining what the form was. "Of course, the form is directed toward the health care professional, specifically physicians, but there are now laypeople in the state who know about the form and have specific wishes that they want to ensure," he says.

The brochure will provide information but direct the patient back to their physicians and indicate how those physicians can obtain the POLST document, he explains.

The group also has become aware of the need for a similar document for pediatric patients. "There is a need in schools and other facilities to have a similar type of form for kids who are particularly ill and have a terminal condition," Dunn says. "There is a group that has been working independently, and as part of a collaborative effort we have invited them to sit down with the task force to see how to use some of our experience to develop a similar instrument for that population."

Although they emphasize that the form is designed for use only in Oregon, the center is making copies and supporting information available to other health care providers who are interested in designing their own program.

Reference

1. Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Ger Soc 1998; 46:1,097-1,102.

Selected reading

• Dunn PM, Schmidt TA, Carley MM, et al. A method to communicate patient preferences about medically indicated life-sustaining treatment in the out-of-hospital setting. J Am Ger Soc 1996; 44:785-791.