The Need for POLST: Minnesota's Initiative

Abstract

In 2008, the Minnesota Medical Association created a task force to develop a standardized Physician/Provider Orders for Life-Sustaining Treatment (POLST) form that could be used throughout Minnesota. Whereas advance directives are created by patients to communicate their wishes about end-of-life care to a physician or other health care provider, POLST forms are used by a physician (or other designated health care provider) to document and communicate a person's end-of-life wishes to other health care professionals, including other physicians. Several states have adopted POLST forms. This article describes the effort to create a POLST initiative and form in Minnesota.

During the last hundred years, life expectancy in the United States has risen by more than 30 years. Much of this increased longevity has been among the elderly, who have gained almost five years of life expectancy since 1950, giving the average 65-year-old an anticipated 18 more years to live.¹ Causes of death have also changed. Acute infection was the predominant mortal disease for much of human history. During the latter half of the 20th century, heart disease emerged as the leading cause of death in this country. Today, death is commonly preceded by years of slow deterioration from Alzheimer's disease, heart failure, chronic obstructive pulmonary disease, complications of diabetes mellitus, and other chronic illnesses. Indeed, diseases such as these account for a greater proportion of deaths now than they did 25 years ago.¹

The prevalence of chronic, progressive, and eventually terminal conditions has led to an increased need to involve patients and family members in decision-making about health care during the last years of life. When people can anticipate death, they have time to make their preferences about the care they would like to receive known to their health care providers. This process, codified in a federal law known as the Patient Self-Determination Act (see next page),² requires that staff from medical institutions inquire about the existence of an advance directive (AD) and provide information relative to health care decision-making rights that exist under state law. Ideally, ADs are the result of a process in which a patient, his or her family members, and health care providers work together to delineate preferences for care if the patient can no longer make those decisions.

The hope for ADs has not been realized. Completion rates have been relatively low, around 10%, according to one of the largest studies of a random sample of all deaths in the United States,³ and 53%, according to a study of the nursing home population.⁴ Even more concerning is the lack of adherence to ADs when circumstances call for their use. There are a number of reasons for this: Often, these documents cannot be found when they are needed, as they may be in a patient's home or with a family member when decisions have to be made. Second, there are a number of different AD forms that patients can use, some of which do not specifically address important treatment decisions that often arise near the end of life such as whether to administer intravenous fluids, artificial nutrition, or antibiotics. Third, because existing AD forms are designed for patients to communicate with physicians, who then decide which interventions are most appropriate given the clinical parameters and the patient's preferences, they cannot be used by nonprescribers (eg, nursing home staff and emergency medical system [EMS] responders) to overrule protocols or institutional policies. Another drawback is that ADs may be difficult to interpret, leaving families and providers to guess about the person's preferences.⁵ Not surprising, studies have shown that since the early 1990s, the care patients receive at the end of life is frequently inconsistent with what they indicated in their ADs.^6,7

As a result of such challenges, a need to better communicate patients' wishes about their end-of-life care was identified. This led to the development of an initiative that has come to be known as Physician Orders for Life-Sustaining Treatment or POLST.

The Concept of POLST

There are key differences between an AD and POLST. The AD is a document that is filled out and signed by a patient. Oftentimes it is created before the patient becomes critically ill. It is intended to communicate the patient's wishes to a physician or other health care provider, as well as the patient's family and caregivers should he or she one day lose the ability to make health care decisions. Advance directives are used to prevent the legal and moral problems encountered in well-publicized cases such as those of Karen Quinlan and Terri Shiavo, where potentially unwanted long-term end-of-life care was implemented.^8,9

In contrast, POLST serves as a tool that can help providers discuss end-of-life treatment options with patients already diagnosed with serious illnesses. Patients have an opportunity to ask detailed questions about treatment options available to them and thereby make informed decisions. Once a treatment plan has been selected by the patient, the provider will sign the form as a medical order, which can then be followed by EMS personnel and other health care professionals during an emergency.

The concept of POLST was formally developed by a coalition headed by the Center for Ethics in Health Care at Oregon Health and Science University in the early 1990s that sought a better solution to the myriad issues that arise with ADs. Several years of focus groups and pilot research culminated in what is now called the Physician Orders for Life-Sustaining Treatment Paradigm Initiative.¹⁰ The initiative's vision is “to ensure that seriously ill persons' wishes regarding life-sustaining treatments are known, communicated, and honored across all health care settings.”¹¹

POLST has already gained widespread acceptance in the state of Oregon.^12,13 It has since spread to several other states including Wisconsin, Washington, West Virginia, California, and New York.¹⁴

Studies on the effectiveness of POLST have been encouraging. A prospective study of 180 nursing home residents in Oregon who designated DNR on their POLST forms found that their wishes were honored 100% of the time.¹⁰ Similarly, another study of 58 deaths of patients involved in a Program of All-Inclusive Care for the Elderly found that 91% of DNR orders were followed. Additionally, use of antibiotics, intravenous fluids, and feeding tubes was consistent with residents' wishes in 86%, 84%, and 95% of cases, respectively.¹⁵ Finally, it has been shown that once POLST gains widespread acceptance in a region, providers such as emergency medical technicians and hospice workers find it easy to use, useful, and influential in making treatment decisions.^12,13

POLST Development in Minnesota

A number of efforts have been made in Minnesota to develop tools in addition to ADs to honor people's end-of-life preferences. In the late 1980s, bioethicist Steven Miles, M.D., and others developed policies for nursing homes regarding Do Not Resuscitate orders¹⁶ and created a form that can be used to state an individual's preference regarding use of cardiopulmonary resuscitation (CPR). This form, still in use, is signed by the patient (or a proxy) and a physician and is accepted as a valid order to withhold CPR by Hennepin County Emergency Medical Services.¹⁷

What is the Patient Self-Determination Act?

Hospitals, nursing homes, home health agencies, and HMOs are required to provide information on advance directives at the time of admission under a federal law called the Patient Self-Determination Act. The act simply requires that most health care institutions (but not individual doctors) do the following:

1. Give you at the time of admission a written summary of your health care decision-making rights (each state has developed such a summary for hospitals, nursing homes, and home health agencies to use) and the facility's policies with respect to recognizing advance directives.

2. Ask you if you have an advance directive and if you do document that fact in your medical record.

3. Educate their staff and the community about advance directives.

4. Never discriminate against patients based on whether or not they have an advance directive. Thus, it is against the law for them to require that either you have or not have an advance directive.

Source: American Bar Association. Available at www.abanet.org/publiced/practical/patient_self_determination_act.html.

In addition to use of this longstanding but limited form in Hennepin County, health care providers in the Duluth area began using a more comprehensive form more than 10 years ago.¹⁸ In 2000 and 2001, the Minnesota Commission on End of Life Care, sponsored by the Minnesota Department of Health, recommended development of a consistent statewide POLST form. At the time, however, the idea had limited support from the Emergency Medical Services Regulatory Board (EMSRB), which must approve use of such forms. For that reason, the idea of developing a POLST form that could be used statewide stalled.

In 2005, the Minnesota Medical Association's (MMA) Ethics Committee resurrected the idea and implemented a task force to create a POLST form. Unfortunately, the form the task force created was deemed to be too intricate to be practical by the state's EMSRB. In 2008, the MMA's Ethics and Medical-Legal Affairs Committee formed an interdisciplinary task force that included physicians and representatives of key nonphysician groups such as the EMSRB, EMS providers, and nursing home administrators and hospice staff, as well as medical ethicists and legal experts to again take up the issue.

The task force compared POLST forms used in Oregon, Wisconsin, Duluth, and in an Allina Health System pilot program in the Twin Cities metropolitan area. The group completed its work on a Minnesota POLST form in October of 2009 and changed the name of the form to Provider Orders for Life- Sustaining Treatment to reflect the idea that nurse practitioners and physician assistants would be signing the form as well as physicians.

The form is composed of six sections (Figure). At the bottom of the first page is a place for the ordering provider (MD, DO, NP, or PA) to sign and date it.

Figure.

Section A

In the first section, the provider delineates the patient's resuscitation status. This section can function both as an inpatient and outpatient DNR order, if DNR is chosen. It is what EMS personnel and nursing home providers will refer to first when evaluating a patient in distress. The phrase “Allow Natural Death” was added to the DNR option in recognition of growing preference for that terminology.

Section B

The second section defines the goals of treatment. It offers individuals three options—one for comfort care, one to limit interventions and treat reversible conditions, and one to authorize life-sustaining treatment. The task force recognized that for patients who opt for comfort care, decisions about whether to call EMS during an episode of acute medical deterioration may arise, especially if the person lives in an assisted living facility. Similarly, when EMS is called, questions about whether the patient should be transported to the emergency room or offered care on site also may come up. In the case where a patient seeking comfort care does go to an emergency room, physicians there need direction about whether or not to admit the patient to the hospital. To address these concerns, the Minnesota POLST form offers options that specifically advise nurses, EMS personnel, and ER staff about the comfort care plan. If the patient wants limited interventions and treatment of reversible conditions, preferences for intubation (short- or long-term) can be specified.

Section C

This section lists specific preferences for use of antibiotics (none, oral only, or IV/IM) and nutrition and hydration treatment. The Minnesota POLST form, unlike those used in other states, differentiates between nasogastric (short-term) and transabdominal (long-term) feeding. The section does have space for additional orders.

Section D

The fourth section summarizes with whom the POLST form was discussed and whether the patients' preferences were based on current or previously stated preferences or on a health care directive. This section allows physicians who receive or transfer the care of a patient with a POLST form (eg, in an emergency room, hospital, or nursing home) to reconfirm the care plan or to change it based on updated information.

Section E

This section lists contact information for the health care professional completing the form. There is also a space for the signature of the patient or health care surrogate. Task force members agreed that a signature was not required to make a POLST form valid in Minnesota because the POLST form serves as a provider order, not as an AD. As with other types of medical orders, the POLST form is always subject to reconsideration by the treating physician should the patient's preferences or medical needs change.

Final Section

The final section lists directions for health care professionals completing, using, and reviewing the POLST form. It will be especially useful during the first stages of POLST implementation, as providers will not be as familiar with the paradigm and form. “Using POLST” instructions offer guidelines for providers treating patients who have a POLST form so that their wishes may be followed as closely as possible. Notably, the POLST form should be reviewed and a new form completed, if necessary, when a patient transfers from one care setting to another, when there is a substantial change in the patient's health status, or when the patient's preferences change.

Implementing POLST

It is crucial to note that, although a POLST form has finally been created for the state of Minnesota, this is only a first step toward making sure patients' end-of-life care wishes are honored. Much more critical is the acceptance and application of the form in nursing homes, hospitals, clinics, hospice facilities, and by EMS providers. It is also critical that the form follow each patient as he or she moves between care settings. In some states, only an original copy of a POLST form is considered valid; and it is often printed on heavy paper. In order to make the POLST form more easily accessible to patients and their providers, the task force purposely refrained from this requirement so that the form could be easily printed, faxed, and stored electronically as part of a patient's electronic medical record. A patient may revoke the original POLST form by instructing their provider to revoke the form, by asking the provider to sign and date an amended form, by drawing a line through it and writing VOID on it in large letters, or by destroying it.

For More on POLST.

The MMA has information about POLST as well as two versions of the form on its website, www.mmaonline.net. There you will find:

• The form as approved by the POLST workgroup and Emergency Medical Services Regulatory Board, bearing the MMA logo;

• A separate copy of the POLST form (which does not bear the MMA logo) that may be modified by providers to accommodate interoffice patient needs or policies. (Note: Altering this form requires review by the EMSRB board for approval);

• Answers to frequently asked questions about the POLST form; and

• Information about upcoming CME opportunities related to the form.

The Oregon Health and Science University's Physician Orders for Life-Sustaining Treatment Paradigm Initiative maintains a website that includes information designed to help others start or improve a POLST program. The website includes a list of state and metropolitan areas that have started programs that have been endorsed by the POLST Paradigm Initiative and key components of endorsed programs. To learn more, go to www.polst.org. Information about the work of the MInnesota POLST task force is available at www.polstmn.org.

Based on other states' experiences, full statewide implementation of the POLST initiative will take years, as providers and patients must become familiar with the benefits of POLST— primarily that it is portable, standardized, and helps to ensure that only appropriate end-of-life care is provided, and is therefore well-suited to today's sometimes fragmented health care system. Nursing homes, hospice organizations, hospitals, and EMS providers will need to update their policies in order to ensure that they accept POLST forms. In Minnesota, the groups that are already using a form of POLST (Allina Health System and providers in Duluth) have agreed to use the new POLST form. In addition, the EMSRB has endorsed this tool and is encouraging EMS medical directors to permit their providers to follow such orders when they are available.

POLST has already shown success in other states, and we believe it will one day become a standard in Minnesota, given the recent endorsement by and ongoing support from the MMA. It is time for providers and patients alike in Minnesota to educate themselves about POLST and begin to view it as a practical and valuable part of end-of-life care. MM