Steve Lai, MD - Long-Term Care Physician

As I walk into the SNF on Monday morning, 3 new patients were admitted over the weekend. I flip through the charts and find each patient has a POLST form with some sections completed along with a request for my signature. I wonder:

• Who had these conversations with the patient and family (If not documented on the back side)? Was it an informed, collaborative discussion?
• Were the decisions unequivocal?
• Does the patient have decision-making capacity (if they signed the form)?
• Did the surrogate make the decisions even though the patient has decision-making-capacity?

POLST (Physician Orders for Life-Sustaining Treatment) is a physician order that outlines a plan of care reflecting the patients wishes concerning care at life’s end. POLST complements the advance healthcare directive (AHCD) to ensure that patient preferences match their values and goals. The AHCD appoints a “proxy” decision maker, which better defines the legally recognized decision-maker.

From the landmark SUPPORT palliative care study ,we found that effective goals of care and end-of-life discussions were poorly conducted in most traditional healthcare settings. This is even more challenging in the long-term care setting given our population of sick post acute care patients, frail custodial patients, staff turnover, heavy work loads, and variable expertise and care process styles. 
  
Since 2008, I have led the Santa Clara County POLST coalition with the mission of educating healthcare professionals on how to have more meaningful discussions with patients and families about goals of care. POLST does not fix end-of-life care, but often can be a catalyst for change bringing the attention of the whole system to advance care planning. For many of us, the POLST has then been a wonderful tool that facilitates these conversations and then documents and translates the resulting decisions into medical orders.

The implementation of the POLST is still in the early stages of use in the SNF setting. As patient advocates we need to protect the integrity of the tool and it’s proper interpretation. We have learned from the introduction of the PIT (Preferred Intensity of Treatment) tools of 1999, that both can be compromised by poor care process design.

In my region in the bay area, many SNFs have delegated the initial POLST conversation to the admissions coordinator. This person may not be a licensed professional and may not have a healthcare background. While AB 3000 does permit any healthcare employee to do this, the basic knowledge required for an effective POLST conversation may be lacking. A far better approach is to have a trained MSW or an intake Nurse(s), assist the patient with POLST completion on admission.

Some facilities have opted to use the POLST form as their admission tool for meeting the regulation that new admissions are informed about their right to have or refuse CPR. Those doing this must realize that completion of a POLST is voluntary and the CPR regulation is met by completion of Section A of the form. Completion of the whole form on admission may not be possible, so these facilities should have a process for continuing the necessary conversations to permit form completion at a later time.

For facilities that are still using the PIT form, they should consider offering a POLST for their patients who might want to limit their medical care in the future, since the orders in Section B and C are much clearer and actionable, then those on PIT forms.

The most difficult aspect of POLST implementation to date has been the relative disinterest of our Attending Physicians. Many seem too busy and comfortable providing traditional medical services to take advantage of the opportunity to have meaningful, goals of care conversations provided by adoption of the POLST paradigm. Many seem all too willing to sign the completed forms without verifying the integrity of the POLST orders. 
  
The POLST coalitions will be addressing this issue in the coming year through targeted training interventions for our Attending Physicians. The coalition has revised the FAQ section on their web site as of March 2012, so that specific questions about the POLST paradigm by professionals can be quickly seen and answered. Please visit this section of the web site to improve the expertise of your staff and your attending physicians. The coalitions look forward to offering further training opportunities targeted for physicians in the coming year.

Please visit the above web site to help us ensure that patient wishes match their treatment preferences and are honored at the end-of-life.

Dr. Steve Lai