Annals of Long Term Care

Introduction
Despite the hope that traditional advance directives would ensure that patients’ end-of-life treatment preferences are honored, numerous studies have found that only 20-30 percent of U.S. adults have an advance directive, and that these documents have limited effect on treatment decisions near the end of life.¹ Some of the limitations associated with traditional advance directives are that they may not be available when needed, are not transferred with the patient, may not be specific enough, may be overridden by a treating physician, and do not immediately translate into a physician order.

The Physician Orders for Life-Sustaining Treatment (POLST) form and program were originally developed in Oregon in 1991, complementing traditional advance directives, to help ensure that patient wishes to have or limit specific medical treatments are respected near the end of life.^2-8 The POLST form is a standardized set of medical orders usually developed by a coalition of citizens, healthcare professionals, healthcare agencies and organizations representing hospice, hospitals, emergency medical services, primary care and long-term care (LTC) professionals, and aging services (Figure). These orders provide guidance to first responders at the time of need, and they transfer with patients throughout the healthcare system serving as portable medical orders.

Programs based on the POLST Paradigm are now implemented throughout or in parts of 15 states. Slight modifications have been made by some states. For example, in West Virginia, the program is called Physician Orders for Scope of Treatment (POST); in New York, it is called Medical Orders for Life Sustaining Treatment (MOLST). The overarching goals are the same. POLST/POST/MOLST orders are intended for persons with advanced chronic illness who wish to turn some aspects of their advance directives or advance care plans into action at the present time to ensure that their medical treatment preferences are respected.

The National Quality Forum recommended use of the POLST program as a preferred practice for quality palliative care, noting that, “Compared with other advance directive programs, POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals.”⁹

This article outlines the elements of a POLST Paradigm Program, describes the current challenge to respect patient treatment preferences at the end of life, and offers a solution and recommendation.¹⁰

The Problem
Mrs. J is an elderly woman with advanced dementia who lives in a skilled nursing facility. She previously completed an advance directive requesting “do-not-resuscitate” (DNR) status and no intensive care. She has also completed paperwork appointing her daughter to make medical decisions. One Saturday night she is found unresponsive with an irregular weak pulse and very low blood pressure. Her facility is unable to reach her daughter, and emergency medical services (EMS) is called. The patient has a dysrhythmia, is resuscitated, intubated, and transferred to the nearest hospital. She is admitted to the intensive care unit and placed on a ventilator. The next morning, Mrs. J’s daughter learns what has happened and demands to know why the nursing home orders were not followed.

Why did this happen? Completing an advance directive or living will is often not sufficient to ensure that patients’ wishes to have or to limit medical treatment will be consistently respected. Advance directives are general statements of patients’ preferences but need to be carried out through specifications in medical orders when the need arises. Without special arrangements, medical orders have limited authority outside of the institutions in which they are written. For example, a physician’s orders at the nursing home usually have no authority in the ambulance or at the hospital.

The Solution
Mrs.