The POLST Illinois Task Force with the Illinois Department of Public Health announced the release of the new Illinois Department of Health Uniform DNR Advance Directive, known as the POLST form.
POLST form
POLST was developed in Oregon in the 1990s, and now 14 states have POLST programs. Twenty-eight states are considering the use of POLST forms.
POLSTs are more detailed than conventional living wills or advance directives. They allow patients to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across care settings and direct doctors to provide or withhold lifesaving treatment.
The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve end of life care in Illinois, is on its way to implementation. Health care professionals met at Rush University Medical Center this week to discuss the form’s development and strategies for raising public awareness.
Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center, provided the audience with hypothetical scenarios the POLST program form could remedy.
POLST program forms are more detailed than conventional living wills or other advance directives. They allow people to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for people who are likely in their last year of life. They can follow patients across in-state care settings and direct doctors to provide or withhold life-sustaining treatment in emergency situations.
The forms aim to more quickly direct doctors to a person’s wishes and eliminate confusion about what patients would want in the case that they are medically incapacitated and unable to communicate their wishes. The forms provide instructions in the case of a cardiopulmonary arrest (the person has no pulse and is not breathing), the degree of medical intervention they would want in a pre-arrest situation (the person has a pulse and/or is breathing), and whether or not they would want artificial nutrition if their medical illness prevented them from taking in adequate oral nutrition.
How a POLST form could help
A 67-year-old man is sent to the emergency room with chest pain and shortness of breath. He is also confused. The cardiologist says that a cardiac catheterization with angiogram and a stent are needed. The nurse tells the physician that there is a DNR order on his chart. Should the physician send the patient for an angiogram? It’s not clear.
If that patient had a POLST form that indicates DNR in case of full cardiac arrest but an order for full treatment in a pre-arrest emergency, the physician would immediately know what to do. The patient would be sent for the angiogram.
An 85-year-old man is admitted to the emergency room with severe pneumonia. He’s hypoxic, confused and refusing the ventilator. There is a DNR order on the charts. The physician feels that DNR doesn’t apply to this potentially reversible condition but the nurses disagree. He receives full resuscitation.
If that same patient had a POLST form indicating no CPR in the case of arrest and a preference for comfort care, the physician and nurses would have clear instructions. He would not have undergone full resuscitation, but would have been maintained in comfort with noninvasive maneuvers. .
A 59-year-old woman who is being treated for breast cancer is admitted to the emergency room for sepsis. She is transferred to intensive care and receives oxygen and maximum vasopressors. She has a DNR order on the charts. The staff are concerned that they are violating her wishes.
If she had a POLST form indicating no CPR in the case of arrest but limited interventions in addition to comfort measures, the staff may feel more comfortable treating her as they are doing and spend less time deliberating.
The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve the quality of end of life care, is on its way to Illinois. Health care professionals met at Rush University Medical Center Thursday to discuss the form’s development and strategies for raising public awareness.
Sample POLST
The Chicago End-of-Life Care Coalition sponsored the discussion led by Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center.
POLST program forms are more detailed than conventional living wills or other advance directives. They allow patients to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across in-state care settings and direct doctors to provide or withhold life saving treatment in emergency situations.
For instance, an individual may choose to decline resuscitation efforts, but of for artificial nutrition. An individual may choose artificial nutrition with set limits or permanent placement.
Goldstein answering audience questions
“POLST improves on the existing uniform DNR form,” said Goldstein. “POLSTs are medical orders and have to be followed by all medical care providers.” To be valid, a POLST form must be signed by an attending physician.
Loretta Downs, president of the CECC, told LMM that POLST is essentially about enhancing personal liberty at end of life. “For Illinois, accepting the POLST form is a statement encouraging people to take advantage of their liberty regarding end of life decisions. It empowers the individual to make a clear statement about whether or not he or she wants end of life care and what level of treatments.”
The POLST form will be available in early 2013, a version of the IDPH DNR Uniform Advance Directive. Goldstein said it will be most similar to the California POLST. The final form awaits approval from state health officials and it may be “ultra pink.”
Many in attendance left hopeful that the form would help their patients. Kriston Kurelic, a social worker at Passages Hospice, says she is excited about the form’s implementation. “I’m very interested in the changes that will happen,” Kurelic said. “It will be very beneficial to long-term care. It will be beneficial to patients and families.”
Christine Nelson, director of nursing at Manor Care, agrees. “I think anything that helps us assess what people’s wishes are more clearly is helpful,” she said. “The only barrier I see is time being taken to explain the form to patients.”
The task of educating patients will likely fall on individual health care providers. Because it is a physician order, it is intended to be accompanied by a meaningful doctor-patient dialogue. Carol Blendowski, a Rainbow Hospice nurse practitioner, says time is what is required to have such conversations, but thinks patients will ultimately find the POLST easy to navigate. “I can see clearly now,” she said. “This form is user friendly.”
POLST was developed in Oregon in the 1990s, and now 15 states have POLST programs. Twenty-eight states are considering the use of POLST forms.
Dr. Hammes, Illinois Hospital Association conference
Chronically ill patients inadequately prepared for the end of life often receive unnecessarily burdensome care, said Dr. Bernard Hammes, keynote speaker at this week’s Illinois Hospital Association Conference. Hammes, of Wisconsin’s Gundersen Lutheran Medical Foundation, developed the program Respecting Choices to teach clinicians about end of life planning.
Hammes maintains that the POLST paradigm is the best program to fix the problem of inadequate end of life treatment, and practitioners should understand POLST as a platform for cultural transformation.
What is POLST?
POLST (Physician Orders for Life-Sustaining Treatment) was developed in Oregon in the 1990s, and 14 states have enacted POLST programs in the years since. The POLST form is now under consideration for use in twenty-eight other states, including Illinois.
POLSTs are more detailed than conventional living wills, and they differ from advance directives. Patients can indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. The forms are intended for patients whose life expectancy is no longer than one year.
“The purpose of POLST is to provide a mechanism to communicate seriously ill patients’ preferences for end of life treatment across treatment settings and to improve the implementation of advance care planning by being more specific,” Hammes said. “POLST works.”
POLSTs do not carry legal weight across state lines, but the forms can act as guidelines for physicians in any care setting. The POLST form is always intended to travel with a patient- whether by ambulance en route to a hospital, or in the instance a patient moves to a long-term care facility.
POLST Coming to Illinois
“There is a national POLST paradigm initiative, there is a task force, I assume that Illinois will become a recognized member,” Hammes told the room of hospice, palliative care, and general practitioners at Northern Illinois University’s Naperville campus.
The Illinois POLST task force is currently working to assemble and educate health workers statewide about the form. The task force is made up of physicians, public health officials, nurses, chaplains and representatives from the Chicago End of Life Care Coalition.
POLSTs may be available in Illinois as early as January of 2013.
Learn more about the POLST form coming to Illinois here.
Family presence during resuscitation, more comfortable patient rooms and grieving spaces are some of the suggestions generated by a survey of 230 emergency department nurses for improving end of life care, reports a new study by the Brigham Young University College of Nursing.
More than 123 million emergency department visits are reported annually, up from 117 million in 2007. “Many patients who arrive for care to help extend their lives instead die while in the emergency department,” reports researcher Renea L. Beckstrand, Ph.D. and her colleagues.
The large number of emergency department visits only exacerbates the ongoing problem of declining access to emergency care. “High patient volume is further complicated by a decreasing number of emergency departments … the emergency department is becoming the portal for inpatient admissions, accounting for 50.2% of nonobstetric admissions nationally,” the study reports.
The study generated almost 300 suggestions for improving care.
Major themes among these suggestions include: allowing emergency department nurses to have more time to care for dying patients, allowing family to be present during resuscitation, and providing more comfortable patient rooms, privacy for dying patients, and family grief rooms. The nurses’ overall concern is for the comfort of dying patients.
Minor themes among these suggestions are: increasing social services and pastoral care, pain management and minimizing suffering, family education, and honoring patients’ desires and wishes, reports Medical Xpress.
According to the researchers: “Caring for those who are dying in emergency departments is difficult because these highly technical departments were primarily created to save lives.”
Despite the considerable obstacles to implementing these new suggestions, the study calls for incremental changes when possible from nurses and hospital staff. The study provided no future date when emergency departments would be fully adapted.
The study concludes: “Emergency nurses witness the obstacles surrounding end of life care in emergency departments, and their recommendations for improving end of life care should be implemented when possible.”
Emergency department nurses are further described in the study as “heroic” for their resourcefulness and commitment to patient care. “As in many other critical care areas of the hospitals, heroic measures often are expected in the emergency department.”
Much of the burden of emergency departments falls on nurses- from withholding life sustaining treatments to comfort care for individual patients.
