Physician Orders for Life Sustaining Treatment (POLST)

IDPH Uniform DNR Advance Directive & the Evolution of POLST in lllinois

Introduction: Advance Care Planning and Advance Directives

Every person has the right to accept or decline medical treatment. This right is maintained even if the person loses the capacity to make medical decisions. One way this right is exercised is through “advance care planning,” which means expressing wishes for future medical care in advance of a health care crisis. A decisional adult can express advance care planning wishes by assigning proxy decision-makers (e.g., “agent”) as well as by stating specific instructions for treatment. These wishes can be put in writing, on forms called “advance directives.” There are a number of state-recognized advance directives in Illinois, including the Power of Attorney for Health Care, the Living Will, the Declaration for Mental Health Treatment and the Illinois Department of Public Health (IDPH) Uniform Do-Not-Resuscitate  (DNR) Advance Directive. Of note, and particular to Illinois, the IDPH DNR Advance Directive document is a patient advance directive that is transitioned to actionable medical orders with a physician signature.

National POLST Initiative

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm program is designed to improve the quality of care people receive at the end of life. It is based on effective communication of patient wishes, documentation of signed medical orders on a brightly colored form, a promise by health care professionals to honor these wishes, and protocols for transportability to assure that the form travels with patients across settings.

Originally developed in Oregon in the 1990’s, there are now officially endorsed POLST programs in fifteen states or regions including California and New York, and an additional 28 states, including Illinois, where POLST forms and programs are in development. The POLST form differs from a typical DNR form in that it addresses more life-sustaining treatment options than just CPR, and it is recognized and honored by all institutions along the health care continuum in the states where it is utilized. The form travels with the patient across the continuum of health care, whether the patient is at home, a long term care facility, hospital or hospice. More information on POLST Illinois is available in the attachments identified at the bottom of this page.

POLST:  The Revised IDPH Uniform DNR Form  

In the spring of 2013, the Illinois Department of Public Health published a revised version of the IDPH Uniform DNR Advance Directive, which may now also be referred to as a POLST form (see the attachment). POLST stands for “Physician Orders for Life-Sustaining Treatment.”  A POLST form is a signed medical order that travels with the patient to assure that a patient’s treatment preferences are honored across settings of care. The POLST model, new to Illinois, is a nationally recognized best practice. For more information on the National POLST Initiative, go to www.polst.org. POLST is designed to:

• Help health care professionals know and honor the life-sustaining treatment wishes of their patients.
• Promote patient autonomy by creating medical orders that reflect the patient’s treatment preferences.
• Facilitate appropriate treatment by emergency medicine and EMS personnel.

Health care professionals and institutional providers are required by law to honor treatment choices shown on a POLST, and are protected from liability if they do so in good faith. Use of the POLST form is voluntary. It may not be legally recognized in other states.

In case of cardiac arrest, the original IDPH Uniform DNR Advance Directive form only allowed a patient to refuse CPR. A critical change with the revised IDPH Uniform DNR Advance Directive/POLST form is that it allows a patient to accept CPR. It is important for the provider to read a completed form carefully, as it is no longer possible to equate the mere existence of the form with a DNR choice. In addition, the revised form addresses more treatment options than the previous version.

The POLST form is an advance directive in accordance with Illinois law. It is NOTintended to replace a power of attorney for health care (POAHC) form. It should be used IN ADDITION to the POAHC form for appropriate patients.   Use of the POLST form will be appropriate for:

• Persons of any age for whom death within the next year would not be expected;
• Patients with advanced illness or frailty and limited life expectancy;
• Patients who may lose the capacity to make their own health care decisions in the next year (such as persons living with dementia); and
• Persons with strong preferences about current or anticipated end-of-life care.

As a screening tool to determine if POLST should be considered, providers should ask:  “Would I be surprised if this patient died or lost decision-making capacity in the next 12 months?”  If the answer is, “No, I would not be surprised,” then a goals-of-care discussion and advance care planning with POLST will be appropriate.

Unless it is the patient’s preference, use of the POLST form to limit treatment is not appropriate for patients with chronic, stable medical or functionally disabling problems who have many years of life expectancy. The POLST form is also recommended for hospitalized patients being discharged to home with hospice, or to a custodial nursing home with or without hospice. It may also be appropriate for patients who have strong preferences regarding artificial nutrition.

If you are interested in learning more about POLST, please view the attachments listed below.  If you require additional information or have questions, please direct them to POLSTIllinois@gmail.com.

May 22, 2013