What is POLST?

Have you heard of the POLST document? If not, you will soon. It is fast becoming a very common document concerning end of life directives that many people are asked to complete before being admitted to an extended care facility and many hospitals.

The POLST (Physicians Order for Life Sustaining Treatment) is not just another advance directive for health care. We are familiar with two kinds of legal Advance Health Care Directives. The living will was the first document developed in the 1970’s to enable people to let the doctors know that they did not want to be hooked up to tubes, respirators, etc. when they are dying. The other type of Advance Directive for health care is a document that appoints someone else to make decisions for you when you are no longer able to make them for yourself. It encourages people to discuss their values and wishes with the person they appoint, the “agent” or “proxy” or “attorney in fact.” Since no one has a crystal ball and knows exactly what their situation will be toward the end of life, it is best to appoint a surrogate decision maker by using this type of directive.

However, the POLST document is not like either one of these advance directives. The POLST is actually a doctor’s order and will override any advance directive. It is an order that is on the chart and will be followed like any other physicians order. The POLST form is a two sided form printed on a bright pink cardboard that is easy to spot in a person’s chart or on a person’s refrigerator at home (which is recommended.)

The POLST was originally written for the terminally ill people who were not expected to live long, less than six months. It is a simple form where it was easy to find the essential information about one’s wishes that would be on one page instead of the four to ten pages that many advanced health care documents contain. It included check boxes that simply stated what one wanted to be done at the end of life. The problem is that since no one can accurately predict what the situation will be at the end of life how can one chose by simple check boxes what one would want at the end of life?

The POLST form has evolved into a document that is used in many different environments. Usually one is encouraged (or mandated) to fill out the form when one enters a senior living facility, a nursing home, and even some acute care hospitals. POLST forms are intended to ensure that the patient’s wishes are respected but what actually happens can be the exact opposite. Facilitators are trained to “help” the patient fill out the form. It can be given to a family member for his or her signature, even if the patient is competent and able to sign it themselves. The form consists of simple check boxes that state that one wants or does not want; these include food and fluid, antibiotics, respirators, CPR (cardiopulmonary esuscitation) etc. These are complicated decisions that must be made while taking the present medical condition as well as the patient’s values and wishes into consideration at the actual time it is to be implemented.

How does anyone chose what one would want when no one knows what the exact situation will entail? These kinds of difficult decisions cannot be made in a vacuum. Checking boxes in a vacuum leaves one highly susceptible to suggestions by those “facilitating” the process of filling out the form. It may well reflect the facilitator’s values rather than the patients.

A huge concern is that if there is a conflict between instructions in an AHCD (Advance Health Care Directive) and the POLST, the law provides that the POLST is to be followed. It is the doctor’s order. So even if one has taken the time to complete an AHCD and discussed their values with the surrogate decision maker, this can be overridden by a simple check box form that may not be what the patient wants at all. What the patient wants could be overridden by another family member.

While the POLST is a simple form that anyone can read “at a glance” at any time and especially in time of an emergency, it does not adequately replace the AHCD. A surrogate, with whom one has discussed their values and wishes, is much more able to evaluate the present actual situation than a simple form that was made out during a different situation at a different time.

It is a fact that most people do not complete an advance directive. Nobody likes to think about end of life; but to insure that your values are upheld when you are no longer able to express them, it is imperative to discuss your wishes with a surrogate decision maker and fill in an Advance Directive for Health Care. There really is no good substitute for wise and loving choices made by a surrogate at the time it is needed considering the burdens and benefits of this particular situation.

BOTTOM LINE: Don’t sign a POLST! If mandated to sign a POLST check the boxes that you want everything. Hospital personnel will then hopefully contact your surrogate for specifics in particular situations.

A PERSONAL STORY: POLST BY TELEPHONE

This is a personal report of the POLST abuse of my 82 year old brother, a 100% disabled Vietnam vet, paralyzed from the waist down, an amputee of his lower right leg, who has lived in severe chronic pain for almost 50 years.

About 8pm, late Sunday evening on January 4, 2015, he arrived by ambulance at a well-known, for-profit rehab facility to rebuild his strength following a short illness and stay in a hospital. He was not there to die nor was he in hospice.

His son, a CPA, was called by telephone regarding his endof-life care. He was preparing for a business trip so he gave by phone the information defining the Advanced Directive he and his dad had worked out carefully well in advance of this situation.

When I went in the next evening, I saw a POLST document on top of his record and asked about it. I was told my nephew had approved it and his signature was on it. I was not permitted to see it or told what treatment my brother was being given. My permission to see his document had not been forwarded from the hospital. My brother was very dehydrated,unable to sit up or feed himself (I spoon fed him and got him to drink water). The next night he was so dehydrated, he drank two pitchers of water with dinner. Some days later, I found that everyone coming into this facility had to have a new POLST done by their staff and no one was admitted to stay there without one.

When I got a copy of the POLST, some days later, I found that they had added to the document with a statement written by a different person. Under the signature line, where an LVN had printed my nephew’s name on the print signature line (not initialized that it wasn’t his signature), the following was written: “Verbal consent obtained 1-04-15 from son_____”, No mention made of consent “obtained by telephone”. Upon the physician’s signature on the 5th, it became an effective Medical Order that healthcare personnel must follow. On the 5th, I was told my nephew had signed it and objected, as I knew he was out of town and could not have seen or personally signed the POLST document!

PART D Information and Signatures, was not filled out! Part D identifies who the conversation was held with, the patient or the agent, who has authority to make decisions given in the Advance Directive, the date of the Advance Directive and signatures. The entire section was left blank.. Not a single question was filled out regarding important information about the Advance Directive. The LVN did not have the Advance Directive and my nephew did not have the POLST while filling out this important end-of-life information on the telephone.

At the top of the POLST document, it states clearly: “Follow these orders, then contact physician.” It also states:“POLST complements an Advance Directive and is not intended to replace that document.” In fact, in actual use, the bright pink POLST is on top of the patient’s records, and does override the Advanced Directive because it is signed and meant as a doctor’s order In taking this POLST by telephone, my brother’s care was radically affected. This document is complex and difficult to understand. Lay people who are not health care people need to study this carefully and not fill it out under duress by a person with a “script” to help you minimize the care your loved one may need and really want. Facilities are embracing this as an easy way for them to handle end of life care so they put pressure for signatures.

At this time, Compassion and Choices, formerly the Hemlock Society, has two bills for expansion of the POLST in the California legislature. One is to establish a POLST Registry for the State of California. At the same time, this bill exonerates all people involved of any malpractice, incompetency, injury to patients etc., under the guise of “good faith” because of the POLST. You will have little to no recourse for litigation for bad care for your loved one with these bills.

The other bill allows a Physician Assistant and Nurse Practitioner to sign in place of the doctor as long as they’re under the authorization of the doctor. In my brother’s case, the doctor merely signed the form after the LVN had filled it out per the telephone conversation with the son. The doctor obviously didn’t look at it or he would have seen that Part D was not filled out. I must emphasize that California Compassion and Choices, promoting the new POLST Registry Act, held a webinar on POLST on December 3, 2014. POLST was promoted as being a “voluntary document”. Dr. Susan Tolles, MD spoke that 160 nursing homes in California have 100% POLST compliance. Voluntary and 100% compliance in 160 nursing homes is contradictory! THIS IS NOT A VOLUNTARY DOCUMENT to people who have to be in these facilities. There was no choice in my brother’s situation.

A number of ethical organizations oppose POLST. Pro-Life Healthcare Alliance states in their document: Opposition to POLST, “Although it is being promoted as an addition to a patient’s own Advance Directive; in practice, it overrides a patient’s previous, carefully prepared advance directive because POLST is a physician’s orders. POLST is tilted toward non-treatment.”

Beware of any POLST you or your agent sign! It may cost you your life prematurely and not in the way you planned by your Advance Directive for Health Care!