Bioethics in Practice - A Quarterly Column About Medical Ethics: LaPOST – Communicating Treatment Goals across the Continuum of Care

After being introduced in Oregon in the early 1990s, laws to allow physician orders for life-sustaining treatment (POLST) have been passed in many states. The Louisiana Legislature passed Act 954 in 2010 to approve the Louisiana Physician Orders for Scope of Treatment (LaPOST). During the last few years, physician leaders and the Louisiana Health Care Quality Forum have worked together to increase acceptance and utilization of LaPOST throughout the state.

Similar to traditional advance directives, LaPOST allows patients and/or their designated representative (healthcare power of attorney) to discuss goals of care with their physician in inpatient or outpatient settings. To complete the necessary documentation appropriately, decisionmaking must be shared and informed. Unlike traditional advance directives such as a living will, however, LaPOST represents a defined set of orders intended to outline a patient's wishes regarding specific care. Additionally, to be valid, LaPOST requires cosignature by the patient or personal healthcare representative and the patient's physician. LaPOST specifically encompasses the following domains of care:

• Cardiopulmonary resuscitation (what to do in the absence of pulse and breathing)

• Medical interventions (what to do in the presence of pulse and breathing)

• Use of antibiotics

• Administration of artificial fluids and nutrition

• Other instructions

The LaPOST order set is portable and accompanies the patient as he/she moves through the healthcare system.¹ That portability is a major advantage of LaPOST because it permits the transfer of orders from site to site along the continuum of care, allowing for a consistent approach to the patient's care regardless of the location. Because of the nature of our health system, caring for patients at Ochsner can span numerous locations. When patients move to another level of care, each step along the way has the potential for a failure to communicate. Because the LaPOST form travels with the patient, the orders remain in force during ambulance transportation and even emergency room admission.

As evidence of the importance of transitions in care, handoffs are areas of particular emphasis by The Joint Commission and the Accreditation Council for Graduate Medical Education when evaluating patient care and training of future physicians. While providers often focus on code status in the acute inpatient setting, LaPOST offers even broader guidance and in less acute settings also.

Several recent publications have demonstrated that the use of POLST orders improves consistency in following patient preferences for care in the nursing home setting.^2,3 Because of its specificity and portability, LaPOST has the advantage of providing direction to all individuals caring for the same patient even in outpatient and long-term settings. Because the document is not limited to resuscitation status, completion of LaPOST encourages a broader conversation to clarify goals of care and to individualize patient preferences.

For additional information, please see www.la-post.org or www.polst.org. The spring and summer 2013 Ochsner bioethics newsletters, available at www.ochsner.org/bioethics, also contain information about LaPOST.