Closure.org Blog

By Marian Kemp

Talking about care at the end of life is not easy. Yet communicating wishes for care in the final months is important. It helps to ensure wishes are honored and eases the burden on loved ones.

Seriously ill patients and/or their families may hear of a document that can help ensure that an individual's health care treatment wishes at the end of life are respected. This document, called the Pennsylvania Orders for Life-Sustaining Treatment or POLST, was approved for use in Pennsylvania late in 2010 by the Secretary of the Department of Health (DOH).

The POLST form is recommended for persons who have advanced chronic progressive illness and/or frailty, those who might die in the next year, or anyone of advanced age with a strong desire to further define their preferences of care in their present state of health. To determine whether a POLST form should be encouraged, healthcare professionals ask themselves, "Would I be surprised if this person died in the next year?" If the answer is "No, I would not be surprised", then a POLST form is appropriate.

The POLST form is not an advance directive, i.e., a living will or health care power of attorney. It represents and summarizes patient choices for care in the form of medical orders. Physicians, certified registered nurse practitioners (CRNP), and physician assistants (PA) use the POLST form to write medical orders to indicate the types of life-sustaining treatment that patients want, or do not want, to sustain their life when they are seriously ill. The form is signed by the physician or CRNP as is any other medical order.

The POLST form remains with a patient if he/she is moved between care settings, regardless of whether the patient is in the hospital, at home, or in a nursing home. A characteristic of the POLST form is that it is brightly colored. In Pennsylvania, the DOH recommends that the POLST form be copied on pulsar pink paper, making it easy to be recognized in an emergency situation.

The POLST focuses on patient-centered goals for care and shared informed medical decision-making. Healthcare professionals complete a POLST form following a discussion with a patient or his/her legal decision-maker if the patient is no longer capable of understanding and communicating his/her own choices for care. Decisions are made in consideration of the benefits and burdens of various treatments. More importantly decisions can be based on individuals' culture, values and religious views.

A significant decision that a patient with a life-limiting condition or the legal decision maker is whether or not cardiopulmonary resuscitation (CPR) should be provided if the patient is found to have no pulse and is not breathing. This choice is indicated in a prominent place at the top of the form.

The form is also used to clarify other types of medical interventions a patient wants at the present time based on his/her medical condition. Some patients who have been experiencing serious illness for a long period of time, who may have had multiple hospitalizations and treatments, may decide following a conversation with the healthcare professional that their preference is "Comfort Measures Only". In this situation, all measures to relieve pain and suffering are provided. Generally these patients would not be transferred to a hospital. However, if comfort needs cannot be met in the current location, a patient would be transferred, for example, someone who sustained a fracture or other trauma.

The form can also be used to clarify if a patient should receive some limited interventions (such as medical treatment, IV fluids or cardiac monitoring) or if full treatment should be provided. Full treatment could extend to mechanical ventilation and attempts at restarting the heart. Intensive care treatment could be provided.

When the form is completed the patient or legal decision-maker is asked to sign the form, thus providing assurance that there is agreement with the orders as written on the form. Healthcare providers will periodically review and update a patient's POLST form especially if there is a change in health status or the treatment preferences change. The orders on a POLST form may be revoked by a patient or the legal decision-maker at any time.

If you or a loved one have a serious illness, ask your physician or other healthcare professional if a POLST form is appropriate.

More information is available online at: www.aging.pitt.edu/professionals/resources-polst.htm or www.polst.org or through the Pennsylvania POLST contact, Marian Kemp, at papolst@verizon.net