Monday, June 6, 2011

Pennsylvania Approves POLST Form - I'm concerned about lack of training requirements

The term POLST stands "Physician Order for Life-Sustaining Treatment." The use of POLSTs is intended to help ensure that patients receive appropriate care at the end of life. This is achieved by creating a actionable medical order that directs care that is consistent with the patient’s goals and preference for end of life care treatment, and is provided in a form that can transfer with the patient as he or she moves between medical providers (such as from a nursing home to a hospital.)

When properly implemented, the POLST paradigm can be particularly effective because it provides treatment directions that are (1) Accurate (2) Actionable and (3) Available.  

POLST is a tool for translating patients’ goals of care into medical orders in a highly visible, portable way. Following the protocol, health care professionals must discuss with seriously ill patients (or their surrogates) the available treatment options in light of their current condition—and help clarify the patients’ preferences. Then clinicians must document those preferences on a standardized medical order form and ensure that it travels with the individual if he or she changes settings of care. POLST differs from an advance directive (living will or health care power of attorney) in that it is an actionable medical order dealing with the here-and-now needs of patients—it can build on an advance directive but can be created for patients without advance directives.

POLST enables patients to choose from a full range of care options, from aggressive treatment to limited interventions to comfort care. Recent academic research documents POLST’s success in improving the documentation and honoring of patient preferences, whatever they may be. Management of pain and symptoms remains comparable to that of patients without POLST. Improving Advanced Illness Care: The Evolution of State POLST Programs, AARP Public Policy Institute, April 2011 (page v).

Act 169 of 2006 required the Pennsylvania Department of Health to consider, in consultation with an advisory committee, adoption of a standardized form for a physician’s order for life sustaining treatment (POLST), which would provide for continuity of DNR and other life sustaining treatment orders from one treatment setting to another.  On November 16, 2010, the Department of Health posted a standard form for statewide use on its website.

The publication of a state approved POLST form should lead to its wide usage especially in nursing homes throughout Pennsylvania.  

 As noted above, the efficacy of the POLST model is dependent upon the accuracy of the medical order. Accuracy would seem to be dependent on the knowledge and skills of the staff involved in counseling the patient and putting together the order. "Garbage in, Garbage out," as the saying goes.

It concerns this commentator that there appears to be no provision in the law or any regulation for training and skill development of the personnel who will be filling out POLST forms.  This raises a serious concern that a patient’s POLST order may be the end result of a lack of understanding by the patient and nursing facility staff and may not state the patient’s actual preferences for end of life care. It may, in effect, constitute a medical order based on uninformed consent.  

Neil E. Hendershot, PA Health Department Posts New POLST Form,

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