Sunday, August 3, 2014

Hospice and POLST: Better Control over End-of-Life Care

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light. 
Dylan Thomas
My sister passed away recently. While she lived in North Carolina and I in Pennsylvania, we were able to remain close via phone. Our once weekly phone calls grew much more frequent during her last months as our time together became all the more dear.
My sister was aware of her impending death. She decided that she wanted to avoid unnecessary, uncomfortable and ultimately useless tests and tubes and procedures. 
Once she made the decision to try to go more gently into that good night, things got much easier for her. She didn’t give up – she just accepted reality and made a decision about the type of care she wanted to receive during the final phase of her life. She chose to end her long battle with her illnesses and seek peace and comfort and dignity. She chose hospice.  
My sister (and her family) had the benefit of excellent hospice care during her final days. Thank you Hospice and Palliative Care Center of Winston-Salem.  
The hospice alternative has become well-known and readily available. As a result there has been increasing use of hospice for end of life care. In 2012, an estimated 1.5 million Americans received hospice care. (NHCPO’s Facts and Figures, 2013 Edition.) 
But many Americans still do receive unwanted care during their last days. The less understood POLST order may be something that patients nearing the end of their lives should be discussing with their physicians.
What is POLST?
Consider the nursing home resident who suffers a medical emergency and is rushed from the home to an emergency room where the medical personnel have limited or no knowledge of their patient’s desires. The patient may have a living will or other advance directive which documents a desire to forgo extraordinary treatment. But it is unlikely that the ER staff will be aware of the advance directive or able to act on it. So the potential for the delivery of well-intended but unwanted medical care is great.
A tool has been developed to help ensure that the patients in this kind of situation receive the treatment they want. It is a standardized form containing physician orders which detail the scope of life-sustaining medical treatment to be provided to patients. These orders are commonly referred to as POLST - Physician-Order-For-Life-Sustaining Treatment. 
The POLST represents an attempt to more effectively implement patient decisions regarding end-of-life care. It helps health care professionals honor the treatment wishes of their patients.  It improves continuity of treatment orders from one setting to another (such as when a patient is transferred from a nursing facility to a hospital or vice versa). 
The physician's POLST order is transferred with the patient when the patient moves to a new health care delivery setting. This helps ensure that the patient's end-of-life decisions will be honored in the new setting. Because the POLST is in a standardized and unique format and is already signed by a physician, it is capable of being implemented at once by any clinician who encounters it.  As a result, the POLST form of instruction directive has shown high rates of compliance and effectiveness.
The President’s Council on Bioethics described the POLST as follows:
"The POLST is a concise form containing specific medical instructions that can be acted on immediately by nurses, doctors, or emergency personnel; it may include "do not resuscitate" and "comfort measures only" orders, and it may indicate whether to administer CPR (cardio-pulmonary resuscitation), antibiotics, intravenous fluids, feeding tubes, artificial respiration, and other medical interventions. Unlike the living will, the POLST governs medical issues that are considered very likely to arise in the near term. According to its developers, it is really only suitable for those expecting to die within the year.” Taking Care: Ethical Caregiving in Our Aging Society, The President's Council on Bioethics, (2005), Chapter 2 - The Limited Wisdom of Advance Directives.
A movement to utilize POLST orders has been spreading throughout the nation. Patients near the end of life and their families and health care providers all benefit from the increased use of this more effective form of combined physician order and advance directive.  
POLST and Hospice are two ways we can better ensure that we receive only appropriate and desired care when our light is dying. Hopefully the POLST order will become better known.   
For more information about POLST see
For more information about Hospice see  

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