“Physician Orders for Life-Sustaining Treatment” (POLST)
Not Just Another Advance Directive (and Coming Soon to a State Near You!)
Ken Norstad (not a real person) is a part-time chaplain at Dignity Hospital. On duty one Sunday evening, he is paged by the nursing supervisor. She asks him to see Mr. Warren, a 66-year-old pre-surgical patient. The unit nurse explains that the patient has questions about “that new Advance Directive” and might wish to complete one. The nurse adds that the questions concern a “POLST” form, which only last month became a legally valid form in their state. Chaplain Norstad has heard about the POLST form but has not seen one. He wonders whether or even how he could be of help to the patient, who is facing surgery in the morning.
The case above (which should be an extreme case) suggests some pitfalls that an unsuspecting chaplain encounters when confronted with POLST for the first time and without orientation. This article highlights several features of the POLST process and POLST forms, partly with a view to the conversation Chaplain Norstad might eventually have with Mr. Warren. In the process it flags some general areas of concern that merit chaplains’ attention, and suggests ways that chaplains can play an important and positive role in the POLST process (Since space does not permit full exploration of the complexities of POLST implementation, readers are urged to consult the referenced sources and the national POLST website). A concluding section will address opportunities and challenges the POLST paradigm presents to chaplains, with special attention to concerns about POLST that have arisen in certain religious and “pro-life” constituencies.
POLST may be characterized as a movement, a “paradigm,” and—most visibly—a form.
Comment on the Case and POLST Overview
In the case at hand, the chaplain is at a disadvantage and is—appropriately—perplexed about how to proceed. With 20-20 hindsight one could wish that Dignity Hospital and its spiritual care department had provided basic information to their part-time chaplaincy staff about POLST with this kind of situation in mind.
Before addressing some specific concerns, it is important to offer an overview of POLST itself. POLST may be characterized as a movement, a “paradigm,” and—most visibly—a form. As a movement, POLST is a nationwide initiative that aims to improve the quality of care for patients at the end of life (see www.polst.org). The POLST movement has developed a “tool” (the POLST paradigm) that ultimately crystallizes “patients’ goals of care into medical orders for a certain subset of patients—those with advanced progressive illness and/or frailty” (Nairn 2013a).
At present the POLST movement is active in 43 states (National POLST 2014a). Nearly half the states have statutes that recognize the POLST form as a valid medical order, and the number of these states continues to grow. The POLST paradigm—which begins with a significant conversation process between a doctor or other healthcare professional and a patient—and the POLST form incorporate a set of nationally recognized best-practice standards for end-of-life care and treatment.
The authorizing POLST legislation and accompanying forms vary somewhat from state to state. Even the acronym “POLST” is not standardized; states have adopted “MOST,” “POST,” and “MOLST,” among others. States’ forms differ in appearance and in content. My state, Illinois, essentially grafted POLST orders onto an existing “DNR Advance Directive” form. The disciplines eligible to sign the medical order also vary; in addition to physicians, some states permit nurse practitioners and/or physician assistants to sign POLST orders (In these states, the “P” in POLST may stand for “practitioner” rather than “physician”).
It should be noted that completing the form and acting appropriately on written POLST orders present providers, including chaplains, with some challenges that require education and attentive practice. Used thoughtfully and alertly, POLST orders mark a positive step forward in respecting patients’ preferences and providing optimal end-of-life care. If used unreflectively or without adequate understanding, they may achieve suboptimal results for patients despite others’ good intentions (Nairn 2013a).
A newly published study of POLST outcomes in Oregon, which has a longstanding, well-regarded POLST program, suggests that POLST orders succeed in ensuring that patients’ wishes for end of life care are indeed honored. “Of patients who requested that, if their conditions worsened, they be given only comfort measures and not be transferred to the hospital, only about 6%” eventually died in a hospital. Medical ethicist Mark Siegler, not known for overstatement, described this outcome as “absolutely breathtaking” (Brotman 2013).
Completing the form and acting appropriately on written POLST orders present providers, including chaplains, with some challenges that require education and attentive practice.
The POLST Form and Process
It is crucial to remember that the POLST form is the fruit of conversations that should be grounded in an advance care planning process (Nairn 2013b). Chaplains with appropriate training can play a helpful role in this process, as the National POLST Task Force recognizes (2014). Informed participation in such conversations does require familiarity with the POLST form and with some pressure points where issues and concerns may arise. What follows is a general discussion of POLST forms and the POLST process, with a focus on areas that may or should be of particular interest to chaplains.
Typically the POLST form begins by offering the option either to require or forgo CPR in the event of a cardiopulmonary arrest. An ensuing section offers a checklist of “level-of-care” options that can be used to summarize the patient’s wishes about overall treatment, given the patient’s current condition and goals for future care. One or more additional sections address more specific medical interventions. The aim here, as in the CPR section, is to allow patients to express their treatment preferences effectively, as components of an “actionable” medical “order set” (Goldstein 2013, p. 22).
Beyond the CPR options, the forms move to more comprehensive orders that implement the “level of care” a patient prefers in the event of a non-arrest, life-threatening emergency.
Resuscitation options and patient safety
It is common to assume that POLST orders always aim at limiting treatment. That assumption misplaces the emphasis. The POLST paradigm seeks first of all “to ensure that seriously ill or frail patients can choose the treatments they want or do not want” (National POLST 2014b). This could sometimes mean more treatment rather than less. For example, the form offers the option to elect rather than forgo CPR in the event of an arrest. Therefore a provider should always consult the form to see whether or not the physician has ordered that CPR be attempted. Especially in an era when patient safety has become a central concern in health care, taking the no-CPR option for granted should never be the provider’s “default.” Chaplains who work with POLST forms might take special note of which option is selected in this area. Similarly, if Chaplain Norstad were to discuss any particulars of the POLST form with Mr. Warren, he would not want to assume that the patient’s interest in POLST automatically implies a desire to forgo CPR.
Level-of-care medical interventions, feeding tubes, and more
As the acronym “POLST” suggests, the POLST form is indeed an actionable medical order set. Beyond the CPR options, the forms move to more comprehensive orders that implement the “level of care” a patient prefers in the event of a non-arrest, life-threatening emergency (Goldstein 2013, p. 24). Although the wording varies, level-of care orders typically encompass these options:
- Comfort measures only: optimal symptom management to relieve pain and suffering;
- Limited additional interventions: comfort measures plus basic medical treatments that may include hospitalization; and
- Full treatment/intubation and mechanical ventilation: interventions that may extend to life support measures in the ICU (with comfort measures as indicated).
In addition, the POLST framework normally includes an optional section offering choices about use or non-use of a feeding tube. In some states the form also provides an opportunity to address other medical options, such as the use of antibiotics.
The level of clinical complexity that is involved in the three level-of-care options, as well as the more specific options, suggests a need for the POLST discussion to include a clinically knowledgeable professional. In any event, Chaplain Norstad will hardly want to undertake a serious POLST discussion in the absence of orientation and some level of training. In-depth POLST conversations are in fact often carried out by trained facilitators, such as healthcare personnel (who may include chaplains) trained in a program called “Respecting Choices,” that is offered through Gundersen Health Systems (Nairn 2013a). If the facilitator is not a practitioner authorized to sign the POLST order set, there is still a need for review and a signature by a doctor or another eligible professional (Nairn 2013a).
In practice, POLST discussions should normally be the “last phase” in a series of advance-care planning conversations that begin when a patient is healthy.
Another important concern in the POLST paradigm is close attention to the identification of POLST-appropriate patients. It is not clear from the case information whether Mr. Warren is actually an appropriate candidate for POLST orders. In a typical advance directive scenario, the issue might simply be whether he is “competent”—has decisional capacity—to express and record his wishes on an advance directive form, such as a living will or power of attorney for health care. POLST is different in this respect. At 66, Mr. Warren is not particularly elderly, and he could be in relatively good health. POLST is intended for patients with advanced, progressive illness and for the frail elderly. A test question that POLST practitioners are invited to ask themselves is, “Is this a patient about whom you would not be surprised if he were to die in the next 12 months?” If the answer is no, a POLST conversation is likely to be mistimed. The patient would not yet be in a clinical circumstance where POLST would be truly appropriate; inappropriate treatment decisions might be made based on a premature choice among the level-of-care interventions (Goldstein 2013).
Some sources do advise clinicians to consider POLST for other patients, particularly those with strong opinions about CPR and end-of-life treatment (POLST Illinois Task Force 2013) who want to insure their wishes are carried out. There is an ethical case to be made for providing these patients with POLST orders. However, any expansion of the POLST-eligible population raises concerns in some quarters, as described below. In general the key factor is “real-time” discussion of treatment options in the context of a medical condition that makes the options more palpable. In practice, POLST discussions should normally be the “last phase” in a series of advance-care planning conversations that begin when a patient is healthy (Goldstein 2013, p. 22). The POLST discussion can include family members if the patient agrees.
Translation of POLST into hospital orders
Since Mr. Warren is an inpatient, if he were to have POLST orders the question of how best to “translate” his POLST order set into specific hospital orders might arise. The correspondence between POLST’s tersely stated level-of-care options and specific treatment options involving vasopressors and other medications, for instance, can be ambiguous. This is not normally a problem for the chaplain to address, but it is a dimension of POLST that chaplains should recognize. Some clinicians have recommended that POLST orders simply replace other in-house orders, but POLST’s level of specificity can leave something to be desired. As Goldstein puts it, “one could argue that ... staff at the bedside would prefer to know exactly which [treatments] to use and which not to use, rather than take precious time to translate the level-of-care orders into orders for particular treatments” (2013, p. 24).
The overriding fear of some has been that POLST opens the door to hastened death and even “stealth euthanasia.”
Advance Directives and surrogate decision-makers
The question often arises whether POLST orders replace or invalidate “other” Advance Directives, especially if there are discrepancies between them. The legal relationship of POLST orders and Advance Directives varies from state to state. In general POLST orders are not considered patients’ Advance Directives (Nairn 2013a) because they are in fact physician orders.1 Further, the patient’s signature is not required on POLST orders in all states (although it is in most). In a handful of states, when there is a conflict POLST orders override advance directives, or the most recently executed document prevails (Nairn 2013a). In practice, such discrepancies have apparently not been a significant problem (Nairn 2013a). A more contentious question can arise in states where a patient’s substitute decision-maker, whether a healthcare agent under a power of attorney for health care or another legal surrogate, may authorize revised POLST orders if the patient loses decisional capacity. There can be ethically sound reasons for this practice, especially when the patient’s condition changes. At the same time, it can raise red flags for healthcare professionals protective of patient autonomy or wellbeing. Chaplains who know the participants and their perspectives may play a helpful mediating role.
More on the chaplains' role
The chaplain’s involvement with the POLST process begins with awareness of the POLST paradigm and the form used in the chaplain’s state. If a state newly adopts POLST, chaplains should take responsibility for learning ASAP about the form and process in their state. They should not take it for granted that their healthcare organization will immediately provide information or education about POLST. They should be proactive in inquiring how their organization plans to handle the POLST process and forms. If the organization plans to treat the chaplains’ role with POLST just like their role with “other” advance directives, the chaplains should advocate for a distinctive multidisciplinary approach along lines discussed here. Similarly, if a state’s POLST statute or form changes, attentive chaplains can help ensure that their organization integrates the changes in its practice.
The chaplain’s constructive role begins with self-education and participation in training about POLST and facilitated advance care planning/POLST conversations. Often, chaplains are already veteran participants in advance directive conversations and advance care planning processes. With their training and experience, and especially with training in POLST facilitation, they can be especially well equipped to engage patients in conversations about the values and goals that inform specific decisions about POLST. Chaplains can also be alert to the issue of patient selection, i.e., whether a particular patient may benefit from POLST orders now or whether, perhaps, the timing for that patient is not yet right. Chaplains can also be alert to concerns about POLST that may arise in local religious and “pro-life” constituencies. Particularly in the Roman Catholic community, there have been vocal critics and even opponents of POLST. The overriding fear of some has been that POLST opens the door to hastened death and even “stealth euthanasia” (Wickman 2010). The perception that POLST is a national movement with political interests, and that it is supported by groups such as Compassion and Choices (formerly the Hemlock Society), has helped to stoke such fears (Brugger et al. 2013).
The sense among some of a POLST conspiracy has been bolstered by specific questions about the POLST paradigm and by theologically based moral objections to it (Brugger et al. 2013) that are more widely shared—even by some states’ Catholic bishops (Johnson 2012). In brief, there have been concerns that POLST orders may be “provided ... to patients who are not near death, particularly in nursing homes; that social workers and others without medical training are counseling patients about their use; and that the training materials emphasize withholding rather than providing care” (Johnson 2012), or stress the burdens of life-sustaining treatments while minimizing their potential benefits (Nairn 2013a). Some have even claimed that the real aim of POLST is to reduce the costs of end-of-life care (Johnson 2012), especially in a time of shrinking reimbursements. It is always possible that abuses of a process like POLST will occur, and there may be a grain of truth in some of the criticisms. At the same time, each has been plausibly answered if not refuted by thoughtful Catholic writers (Nairn 2013a; Coleman and McLean 2012). As one article summarizes the matter, “in themselves, advance directives and POLST not only do not contradict Catholic teaching but [they] also facilitate communication, difficult decision-making and patient-centered care” (Coleman and McLean 2012, p. 62). Non-Catholic chaplains who have contact with Catholic patients or residents—and especially those who serve in Catholic facilities—will at least want to be aware of the concerns and the discussions surrounding them. The advent of POLST provides another avenue for patients to state and implement preferences for care near the end of life. Rightly used, the POLST paradigm promotes enhanced respect for patients’ preferences and patient-centered care at the end of life. POLST orders and, especially, the discussions that lead to their formulation can help people feel that their dignity and worth have been—and will be—respected in the care they receive. Chaplains can play an important, even vital, role in this process.
1 Illinois’ form, with POLST orders embedded in a “DNR Advance Directive,” is arguably an exception.
Brotman, Barbara (2014). “Expansion of End-of-Life Care Order Awaits Governor’s Signature (Study Shows POLST Directive Successfully Gives Patients Control over Where They Die),” Chicago Tribune, June 16. Accessed July 1, 2014, at http://articles.chicagotribune.com/2014-06-16/news/ct-polst-end-of-life-directive-20140616_1_end-of-life-advance-directive-medical-order.
Brugger, Christian, et. al. (2013). “The POLST Paradigm and Form: Facts and Analysis.” Linacre Quarterly 80, no. 2 (May): 103-138.
Coleman, Gerald D., and McLean, Margaret R. “POLST Supports Care in Context of ERDs” (2012). Health Progress 93, no. 6 (November-December): 58-65.
Goldstein, Julie (2013). “Illinois’ New Uniform DNR Advance Directive,” Chicago Medicine, October, pp. 22-25. Accessed June 28, 2014, at http://www.cmsdocs.org/news-publications/chicago-medicine-magazine/2013-issues/Oct2013Issue.pdf.
Johnson, Annysa (2012). “End-of-Life Medical Care Initiative Prompts Worries about Abuse.” Milwaukee Journal-Sentinel, October 16. Accessed July 2, 2014, at http://www.jsonline.com/news/health/endoflife-medical-care-initiative-prompts-worries-about-abuse-pv71jc9-174491051.html.
Nairn, Thomas (2013a). “The Catholic Medical Association’s White Paper, ‘The POLST Paradigm and Form: Facts and Analysis,’” Health Care Ethics USA 21, no. 3: 17-36.
__________ (2013b). “POLST: A Portable Plan for Care.” Health Progress 94, no. 6 (November-December): 87-89.
National POLST (2014a). “Programs in Your State.” Accessed June 28, 2014, at www.polst.org.
__________ (2014b). “What Is POLST?” Accessed June 28, 2014, at http://www.polst.org/programs-in-your-state/.
National POLST Paradigm Task Force (2014). POLST Legislative Guide. Accessed July 2, 2014, at http://www.polst.org/educational-resources/legal-and-policy/.
POLST Illinois Task Force (2013). Guidance Document for Illinois Health Care Professionals and Providers: Illinois Department of Public Health (IDPH) Uniform Do-Not-Resuscitate (DNR) Advance Directive/Physician Orders for Life Sustaining Treatment (POLST), August, p. 3. Accessed July 2, 2014, at http://www.siumed.edu/medhum/POLST/2013-August8/Guidance Document.pdf.
Wickman, Elizabeth. ”Repackaging Death as Life—The Third Path to Imposed Death” (2010). Paper presented at the 2nd Annual Life Conference, Raleigh, North Carolina, October 23.
David McCurdy, BCC, editor of the first two issues of Caring Connections, is an adjunct faculty member in religious studies at Elmhurst College. He recently retired from a position as senior ethics consultant and director of organizational ethics at Advocate Health Care. He has been teaching and consulting about healthcare ethics issues, including end-of-life concerns and advance directives, for nearly 30 years. McCurdy welcomes questions or comments about this article at email@example.com.
Portions of this article draw from material that previously appeared in Cases in Ethics, an internal publication of Advocate Health Care..