by Timothy Gieseke, MD, CMD

At the recent national POLST meeting, a case of a patient unwilling to complete a POLST was discussed.  As the WAVE readers are probably aware, POLST is not generally recommended for patients unless they are in the last year or so of life.  In this case, in a nearby state, a SNF demanded that a total joint patient with a good prognosis complete and sign the POLST as a condition of admission to the facility.  When the patient refused, the facility refused to admit him.  In this state with a mandatory registry, what would be the implications of this “inappropriate” patient’s POLST form becoming a part of their electronic registry?

In California as in all states, completing a POLST is the patient’s choice and can’t be a condition of admission.  Prior to the POLST, facilities met CMS’ mandate for determining advance care planning and goals of care status on all admissions by use of PIT (Preferred Intensity of Treatment) or PIC (Preferred Intensity of Care) forms. With the introduction of Section S (POLST reporting on section S for MDS) in California, many facilities seem to be under the mistaken impression that they are being graded by CMS or CDPH on how many POLSTs they do.  Certainly considering the advantages of the POLST as a document that more precisely supports advance care planning and the appearance of POLST on Section S, it’s no surprise that many of the facilities in my community have switched from PIT forms to having POLST forms as part of their admission package.  While these facilities are aware that this is optional and certainly would not refuse a resident admission because he would not sign a POLST, it does raise questions about whether some patients are coerced to complete a POLST as in the above case.  

The practice of placing POLSTs in every resident’s admission paperwork has also resulted in charts with POLST in a chart that are signed by the physician with no choices indicated and no signature by the patient or DPOA.  If that occurred, even though the POLST isn’t valid (section A choice and both signatures needed), the law says that by default, the patient has chosen Attempt CPR and Full Treatment status.  But what is more concerning is that a physician would sign a document that has life-and-death implications without taking the time to determine what the patient (or surrogate) would want—it’s basically like signing a blank check… or a blank death warrant!

As I was reviewing a chart yesterday at a facility, I discovered a POLST from an admission in December 2015 with no choices and no patient signature.  I asked for the details, and the patient care coordinator informed me that the patient had persistently declined to complete any part of the form, but was aware of the default choices.  In an emergency, I wonder how this would play out when the nurse sees the blank form, lets the on-call doctor know about it, and then has paramedics and emergency room personnel respond to this POLST.  That nurse may not readily have the advance care planning process information available, that I learned from the patient care coordinator.  On discharge, does this essentially meaningless form go home with the patient, since the POLST is designed to follow the patient across the settings of care?  In addition, as our state develops an electronic POLST registry, would this document from an unwilling patient be posted?

I asked one of my facility DONs about whether they had a POLST policy and whether all their licensed staff were trained to deal with this situation or whether this situation was covered in their policy and procedure manual.  In fact, the facility did not have a POLST policy.  I advised her that a model policy for SNFs is available at no charge on the Coalition for Compassionate Care of California website (http://capolst.org/polst-for-healthcare-providers/#resources ).

To clear up the potential for confusion about a POLST in an inappropriate or unwilling patient in the SNF setting, CALTCM, CAHF (California Assoc. of Health Facilities), and the Coalition for Compassionate Care of California are committed to working with the CDPH for the creation of an All-Facilities Letter that will provide a reminder, and clearer guidance, on the voluntary nature of POLST.    

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