Meeting Death on Your Own Terms: The POLST Form

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Original story posted on: August 30, 2017

In the 1934 movie “Death Takes a Holiday,” Death, played by the venerable Fredric March, takes a three-day holiday to find out why everyone fears him. During his respite, no one dies from disease or accidents.

Unlike in the movie, in real life Death doesn’t go on vacation but works day and night. Everyone alive knows this. You would hope that everyone would be ready to meet death when it comes – but that’s not always the case.

For those whose time is running out and will likely meet Death face-to-face in the next year, getting ready to pass on their own terms has gotten easier and simpler.  The POLST (Physician Orders of Life-Saving Treatment) form allows the dying to to set the conditions of their passing. It is an innovative and effective program that gives patients the ability to set controls regarding how and when they die.

Who in healthcare doesn’t know about this life-changing form? Well, during a recent presentation on palliative care, I found out.

Standing on the rostrum last April, I pondered about even asking the question. I thought it was too simple. I thought it had too obvious an answer. From the speaker’s podium I surveyed the hand-raising pool of quality and utilzation professionals in the conference room. Anticipating a forest of hands to rise up, I decided to ask the question of the 232 people in the room:

“How many of you are familiar with the POLST form?”

Expecting a forest, I got just one tree: a single hand rose up.

I was astonished. I had hesitated to even put slides about the POLST  form in my presentation. I assumed everyone was aware of it. It has been around for years, it has a website, a Google search results in 524,000 results, 47 out of 50 states have POLST programs, and  both major medical  journals and major newspapers  had recently run articles on the topic.

But I shouldn’t have been stupified, because the estimated length of time for a practice-altering development to be implemented, prior to the advent of the Internet, was almost 17 years! It traditionally has taken that long for the general medical population to absorb and translate changes – but the specialty populations  have a much shorter turnaround.

Since I live part-time in the world of palliative care, I became  familiar with the POLST form early. I tracked our state’s adoption of its POLST form and I prostetylized for its use. However, for the POLST form to succeed, it needs more than proselytizers, it needs the medical congregation – the community physicians and nurse practicioners – to become informed believers.

So, what is this POLST form, with which 99.57 percent of my audience was unfamilar? It is one of two documents that can ensure that a patient’s treatment preferences are verified, updated, and most importantly, respected. The other document is the advanced directive, a.k.a. the living will. These forms do not compete with each other; they complement each other.

Both the POLST form and advanced directive document each patient’s goals of care and treatment preferences, but the preferences expressed in a living will are just that – only preferences. The POLST form, however, contains actionable, signed medical orders based on those preferences.

In the home, living wills inform EMTs what each patient’s preferences are, but it does not absolve them from following emergency protocols. The POLST form contains care providers’ orders that override protocols and allow EMTs in the field to act in accordance with patient wishes. In the hospital, physicians and nurses are likewise bound to follow the POLST orders.

The table from the the National POLST Paradigm website (www.polst.org) gives a brief comparison of the POLST form, along with the advanced directive:

Salvatore 083117

One of the reasons my audience may not have heard about the POLST form is because it might be called something else in their state. Individual states vary, with the most common other names being the MOSLT, MOST, and POST. In my state, Delaware, it is called the DMOST. If you are wondering about what the POLST form’s name is in your state, you can easily find it online at http://polst.org/programs-in-your-state/.

There is another significant difference between the POLST form and living wills that is changing the medicolegal landscape: the concept of “wrongful life.” Traditionally, “wrongful death” was the only focus of lawsuits, because the law did not consider survival to be a harmful outcome. Now a patient can be “wrongful alive” as well as “wrongfully dead.”

When a POLST form orders for DNR/DNI are not respected and CPR results in an unwanted survival, patients and their families are suing due to “wrongful life,” i.e., being kept alive against their expressed wishes and healthcare provider’s POLST orders. POLST forms are powerful documents that translate patient wishes into healthcare directives.

The POLST is here to stay, and while it has not obviated the need for an advance directive, it has revolutionized how patients’ preferences for care are achieved. The POLST is easy to complete for patients, easy to interpret by caregivers, and easy to find by EMTs. Most POLST forms hang on refrigerators for easy access in a crisis.

The POLST form has tremendous potential: the potential to instigate meaningful end-of-life discussions between patients, families, and doctors; the potential to save countless sorrows and dollars; and the potential to allow our patients who are facing death to decide how they will meet it.

In the end, the POLST form is all about the end. It allows our patients to write the scripts for their own deaths. Most patients live the life they must, while the POLST gives all patients the means to die the death they choose.

Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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