Saturday, February 17, 2018

POLST End-Of-Life Bills Deserve Support

The Pennsylvania Legislature is considering two bills intended to improve the use of doctor’s orders for end-of-life medical treatment. House Bill 1196 and Senate Bill 623 would standardize POLST orders and provide guidance and education to health care providers. 
What is a POLST order
 The acronym POLST usually stands for "Physician Order for Life-Sustaining Treatment."  But the Pennsylvania bills change the name to “Pennsylvania Orders for Life Sustaining Treatment.” A POLST orders is intended to direct treatment so that patients receive only appropriate and desired care at the end-of-life. This is achieved by creating an actionable medical order that directs care that is consistent with the patient’s goals and preferences for end-of- life treatment. A POLST order 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.)

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 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 (but not mandatory) for voluntary statewide use on its website. But much more has been needed.
 Education and Training are Key
 Right now, the use of POLST orders in Pennsylvania is largely unregulated. There is no provision in current law regarding training of the personnel who are advising patients. Facility staff who have received little or no training may be the ones guiding patients in understanding, determining and documenting their treatment preferences. As a result, a patient’s POLST order may be the end result of a lack of understanding by the patient and facility staff and may not reflect the patient’s actual treatment preferences. It may, in effect, constitute a medical order based on uninformed or misinformed consent.
 If enacted the current legislation will help remedy the situation. The bills require the Department of Health to develop recommendations for training of health care practitioners and others who educate patients about POLST or assist in completion of a POLST form. (See HB 1196, Section 5498.1(c). While providers may not technically be required to follow the recommendations and train their staffs, the existence of recommendations and material should help that happen.  
  The House and Senate bills are at this point virtually identical. Both call for creation of a mandatory POLST form and the development of educational materials on POLST orders. The bills create standards for a valid POLST order and provide immunity to health care providers who follow an order in good faith.
 Other Provisions
 The legislation sets forth requirements for emergency medical services personnel regarding their compliance with a POLS order. It also provides for involvement by a patient’s surrogate health care decision makers, who are defined in Section 5493 as: “A health care agent, health care representative, guardian of the person or parent of a minor who is legally authorized to make a health care decision for a patient.”
 Responsibility for implementation is given to the Department of Health which is directed to create a POLST Advisory committee to assist it. The form and educational materials will be available online.
  The bills create an alternative to the normal regulatory process. Notice and opportunity for public comment are required when the mandated POLST form is created or modified but the normal regulatory process is avoided.
 This legislation was drafted by a committee of stakeholders who had to claw their way through a number of divisive end-of-life issues. The bills move the ball forward without attempting to resolve all contentious issues. Much is delegated to the Department of Health and its advisory committee. I think this is a reasonable approach if you actually want to pass legislation in this area.
 My overall impression is that this is well considered and articulated legislation that is deserving of support. Perhaps it does not go far enough in some respects – for example, it appears that providers will be encouraged but not required to get educational training for their POLST involved staff. But it is a step in the right direction if you believe that patients end-of-life decisions should be better counseled, supported and implemented.