Defining life-sustaining preferences
Physician orders for life-sustaining treatment (POLST) is a single-page medical order form, typically printed on bright pink paper, and signed by a physician, nurse practitioner, or physician assistant to spell out treatment preferences for a seriously ill or frail patient. It is also a process for exploring those preferences in conversation with patients and then communicating them to those who might need to know, such as EMS personnel, in some future medical emergency when the patients can no longer speak for themselves.
Dr. Pantilat
And, said Steven Pantilat, MD, FAAHPM, MHM, a former clinical hospitalist and the inaugural chief of the division of palliative medicine at the University of California San Francisco, it is “solidly within what hospitalists can and should be doing.” That may involve meeting and talking with patients and their families about their values and treatment preferences, reviewing any existing POLST forms, and even filling out and signing a form.
When a patient completes a POLST form at UCSF, Dr. Pantilat said, a ward clerk can upload it to the hospital’s electronic health record (EHR). “An advantage of POLST in the hospital is that when I sign it and the patient signs it, it’s done.”
A legal medical order
POLST includes information and options regarding cardiopulmonary resuscitation, artificially administered nutrition, and several other medical options—with choices ranging from full treatment to comfort-focused treatment only—along with the necessary signatures. It is recognized as a legal, actionable medical order in many states, while most of the other states are developing policies and regulations to recognize an executed POLST form.
POLST was first implemented in Oregon in 1995 to address the common problem of not being able to locate and thereby honor the life-sustaining treatment preferences of patients. Originally named “Physician Orders for Life-Sustaining Treatment,” today it’s often called a “portable medical order,” meaning it’s valid in community settings, or just plain POLST. Some states use alternate terms like MOLST (Medical Orders for Life-Sustaining Treatment), or POST and MOST, for a similar document.
But POLST is not just a medical form. It is a tool that can help medical practitioners, including those working in hospitals, to provide individualized, compassionate care aimed at honoring patients’ wishes and deeply held values in the context of what is medically achievable for them—while helping to prevent unwanted or inappropriate treatments.
“POLST complements patients’ advance directives, although it is different than those. It is an actual physician order that is meant to guide care in the home or long-term care setting in specific ways,” Dr. Pantilat said. “The way I think about it is that when POLST is most useful—and typically the only time I fill it out—is when someone wants a code status other than full code. If the patient’s preference is full code, full treatment, then I’m not sure you have to document that (on a POLST form) unless you think there’s some reason why it would not be respected in the setting in which the patient is located.”
“When I’m seeing patients, as soon as I hear that they don’t want to be full code, I’m already thinking I should pull out a POLST form and get it done before discharge. And then you can use it to guide a conversation that is specific to their circumstances.” Hospitalists are concerned with the patient’s care in the hospital but also about what happens after they go home, Dr. Pantilat said.
More than just checking boxes
Dr. Razzak
“As hospitalists, we should be able to review the patient’s care preferences upon their admission to the hospital. Are those consistent with what’s going on medically and what’s achievable?” said Rab Razzak (@rabrazzak), MD, a hospitalist and clinical director of palliative care at University Hospitals Cleveland Medical Center in Cleveland.
Whatever the patient chooses is important, Dr. Razzak said. “We need to help them better understand what those choices mean. The problem is we sometimes just accept what the patient says, even when what they say may not be consistent with what is medically possible.” When needed, he said, the hospitalist can offer patients more guidance on what is possible.
“We should be having conversations about what this all means to them, including prognosis and natural history of the disease, if they want to know,” Dr. Razzak said. Fostering improved communication, asking what is most important to the patient, “This is the work we need to do in order to provide better and more personalized care. Our clinical institutions and groups should be supporting that. Obviously, it requires some time in order to a good job,” he said. If hospitalists are seeing too many patients in a day, they won’t do as good a job on these conversations.
Dr. Razzak serves on SHM’s Palliative Care Task Force, led by Wendy Anderson, MD. This group helped to develop the “Hospital Prognosis and Goals of Care Communication Pathway” of key communication processes within the typical workflow of hospitalists and their teams.1 One of its recommendations is for the hospitalist to review established care preferences, such as those captured in a POLST form, at the time of admission to the hospital. “If POLST is in the chart, does it still apply? Can we update their POLST form by the time of discharge?” Dr. Razzak said.
A 2020 study in The Journal of the American Medical Association examined the association between POLST orders specifying treatment limitations and admissions to the ICU for hospitalized patients nearing the end of life in a two-hospital academic healthcare system.2 It found that treatment-limiting POLST orders were significantly associated with lower rates of ICU admission, compared with POLST orders specifying a full-treatment approach. However, 38% of patients with treatment-limiting POLST preferences still received intensive care that was potentially discordant with their care preferences.
Meeting the patient and family
Dr. Gundersen
Elizabeth Gundersen (@top_gundersen), MD, FAAHPM, FHM, a former hospitalist and associate professor of hospice and palliative medicine at the University of Colorado’s Anschutz Medical Campus in Aurora, Colo., said she is sometimes asked what “serious illness,” a common indicator for POLST appropriateness, means.
“I say a serious illness is one that has a high probability of morbidity or mortality for the patient—with a high likelihood of complications and of coming back to the hospital,” she said. She adds that a useful question for the clinician to ask is, “‘Would I be surprised if this patient died in the next year?’”
One of the barriers to hospitalists using the POLST form with their patients is their limited time, Dr. Gundersen said. “But if you have a patient that you’re seeing who has a serious illness and has been in the hospital frequently, and your intuition is telling you they are at risk of showing up in the hospital again in the not-too-distant future, those are patients for whom it would be worth sitting down and having a full goals-of-care conversation,” she said.
“I did this recently with a family. We had a family meeting and they decided to shift the focus of care for their loved one to comfort. Our hope was that we would be able to send the patient home on hospice care. And we established all of that in a big, emotional family meeting,” Dr. Gundersen said. “Then, at the meeting’s end, I said, ‘We have this form that we use to document everything that we just talked about so that your loved one will be protected (from unwanted medical care) when she goes home with hospice.’” It applies, she adds, even to what might happen en route to her home.
Dr. Pereira
As a hospitalist, introducing goals-of-care conversations during the initial encounter can be challenging and requires a certain level of sensitivity, empathy, and effective communication, said Salonie Pereira, MD, associate site director of the division of hospital medicine at Long Island Jewish Medical Center and assistant professor of internal medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New Hyde Park, N.Y.
“I often aim to establish at least a day or two, if possible, to introduce myself, get to know the patient and their caregivers, provide information on the diagnosis and care plan, and reinforce my role in their care. I then ask all my patients with advanced illness about their advanced directives, their healthcare proxy, and their preferences for medical interventions so as to align their values with the medical plan,” she said.
In certain situations, a member of the palliative care team will accompany the hospitalist for a joint family meeting offering enhanced support and expertise in shared decision making, she said. The Advanced Illness Team at Northwell Health also conducts a three-hour training program for its clinicians, using simulated patients to offer experience in goals-of-care conversations.
Incorporating POLST into the EHR
Dr. Patel
Mihir H. Patel (@mhp0023), MD, MPH, MBA, FACP, CLHM, SFHM, medical director of virtual medicine and chair of the inpatient clinical informatics council at Ballad Health in Tennessee and Virginia, chair of SHM’s Health Information Technology Special Interest Group, and a practicing hospitalist, said hospitalists are the primary point of contact for patients in the hospital and can facilitate the communication of patient preferences and values by initiating conversations about POLST.
“Verifying that the patient and family understand their choices and that the POLST form accurately reflects their wishes is essential,” he said. “Hospitalists have the unique advantage of seeing the same patients daily, sometimes multiple times a day, during their hospital stay. This continuity allows for in-depth conversations and multiple touchpoints with the patient and family, which is typically not possible in an outpatient setting.”
For Dr. Patel, incorporating digitalized POLST forms into a hospital’s EHR ensures that patient preferences are accurately documented and easily accessible. “The digitalization of POLST forms involves transforming paper forms into electronic versions (ePOLST) that integrate seamlessly into EHRs,” he said. There are two formats for integrating POLST within an EHR: paper POLST form upload and storage in the EHR, and an electronic POLST (ePOLST) completed electronically.
Implementation of ePOLST should follow document and messaging standards (e.g., HL7), Dr. Patel said. Depending on state laws, an ePOLST may still need to be printed, signed, and scanned into the EHR, with a copy given to the patient.
Technological solutions
There are other technological solutions such as mobile apps and electronic repositories for POLST documents, Dr. Patel said. Vynca and MyDirectives are examples of online repositories that allow online creation, signing, and storage of POLST forms, which can be integrated with healthcare or EHR systems.
Some hospitalists may not be fully familiar with the purpose or legal implications of POLST forms, leading to potential misinterpretations, educational gaps, communication breakdowns, or family conflicts, he said. Failure to update a patient’s POLST form regularly may result in a document that no longer reflects the patient’s current wishes. It is also important to make sure the family understands what’s on the signed form.
For a hospital that does not have a formal program to encourage easy access and storage of POLST forms for its patients, the hospitalist may be the obvious choice to champion such a POLST initiative, he said. Start by reaching out to the C-suite, the medical executive committee, and the hospital’s ethics committee for their support. Comprehensive staff training about POLST should target physicians—both hospitalists and intensivists—as well as primary care physicians in the clinic setting, nursing leadership, the emergency department, and long-term care facilities with working relationships.
Plan to collect data on usage, rate of adherence to patients’ expressed wishes, and patient and clinician satisfaction. Make sure the forms are easily accessible, both electronically and on paper, throughout the hospital. Providing decision support tools within the system and ensuring interoperability are two other important goals.
Honoring patient values and preferences, with the help of POLST, could be an obvious target for quality improvement initiatives, experts interviewed for this article noted. “If you’re looking at this from a practical standpoint, not only is it the right thing to do for patients, but it can impact quality metrics like ICU admission rates or in-hospital mortality,” Dr. Gundersen said.
“I’ve always felt hospitalists are the ‘home team’ for both hospitalized patients and hospitals,” she said. “Championing POLST is an excellent thing for hospitalists to do within their division. We want to see this form used more often because of the benefits it has for our patients. Work with your hospital leadership for system-wide buy-in. Talk to the leadership about how this is good for everyone.”
Larry Beresford is an Oakland, Calif.-based freelance medical journalist, and long-time contributor to The Hospitalist.
Learn more about POLST in this article Clinical Scenario: Patient Care Through POLST.
References
- Anderson WG, Berlinger N, et al. Hospital-based prognosis and goals of care discussions with seriously ill patients: a pathway to integrate a key primary palliative care process into the workflow of hospitalist physicians and their teams. Society of Hospital Medicine and The Hastings Center; 2017. https://production.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/ctr-17-0031-serious-illness-toolkit-m1.pdf. Accessed August 30, 2024.
- Lee RY, Brumback LC, et al. Association of physician orders for life-sustaining treatment with ICU admission among patients hospitalized near the end of life. JAMA. 2020;323(10):950-60.