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At the heart of modern health care is the patient’s right to choose or to reject medical treatment.¹ This concept of autonomy or self-determination provides that competent adults have the right to refuse medical treatment, even if it means they may die.²

Issues regarding decision-making by patients are rare when the patient is competent. Complications arise, however, when patients are no longer able to speak for themselves. In the years since the Quinlan and Cruzan cases, the use of advanced care planning documents that are generated by patients, such as living wills³ and health care powers of attorney,⁴ have became more acceptable. The goal of these planning tools for advance care is to allow individuals to retain control over decision-making when they can no longer speak for themselves.

Recent studies have shown, however, that these traditional methods for communicating preferences about life-sustaining treatment at the end of life are largely ineffective. Living wills and other advanced care planning documents may be unavailable, vague, or have been written so long ago that they are not relevant to the individual’s current medical condition.⁵

In response to the shortcomings identified in traditional tools for advance care planning, the Physicians Orders for Life Sustaining Treatment (POLST) Paradigm program was initiated in Oregon in 1991⁶ to help health care providers honor the treatment preferences of their patients. The POLST program is designed for seriously-ill individuals with life-limiting or terminal illnesses, and is intended to accomplish two major goals for end-of-life decision making:
a) document the treatment preferences of an individual with actionable medical orders;
b) assure that the orders move from one care setting to another with the individual (home to hospital, etc.).

The POLST form contains medical orders that are actionable, just like any other medical order, and can, therefore, have a direct and immediate impact on the course of an individual’s care. Unlike do-not-resuscitate orders, the POLST form is not intended to merely limit the treatment provided to an individual. Rather, it is a mechanism for individuals to express their preferences about levels of treatment, and can indicate either full treatment (including resuscitation) or it can be used to limit treatment (do-not resuscitate).

In October 2010, the Secretary of the Pennsylvania Department of Health (DOH) approved the use of a standard form to be called the Pennsylvania Orders for Life Sustaining Treatment, thus redefining the POLST acronym for Pennsylvania. The official POLST form was posted on the Department of Health website in November 2010. This form uses the POLST paradigm form, but is consistent with Pennsylvania’s laws related to advance care planning.⁷ The Pennsylvania form was developed by the Department of Health’s Patient Life Sustaining Wishes Committee and was designed to be consistent with Pennsylvania law. There are significant advantages to using a form that contains standardized language and is produced in a distinctive and easily recognizable format.⁸

The POLST is a form printed on bright pink paper that is completed after a shared discussion of an individual’s treatment goals between the individual (or his or her surrogate decision-maker) and the individual’s health care provider. It is signed by the individual (or surrogate) and by the provider.

The completed form accompanies the individual from care setting to care setting – for example, from the home to a skilled nursing facility to a hospital. Nonetheless, it is recommended that the POLST be reviewed by the health care provider with the individual (or surrogate) when the individual changes treatment location or experiences a significant change in condition. This is to ensure that the POLST still adequately reflects the individual’s treatment choices.

In June 2010, the Lancaster County POLST Coalition, under the leadership of Lancaster General Health, Ephrata Community Hospital, Hospice of Lancaster County, Lancaster Emergency Associates, and Lancaster Rehabilitation Hospital was formed to implement the POLST paradigm in Lancaster County. The Coalition includes all Lancaster County acute care hospitals; Hospice of Lancaster County; many long term care and rehabilitation facilities; home care and hospice agencies; the Lancaster County and City Medical Society; and the Lancaster County Bar Association. Each facility has been working to implement policies and procedures to make POLST available to appropriate patients and residents.

As a leader of the Lancaster County POLST Coalition, Lancaster General Health has fully implemented POLST at both the Duke Street and the Women and Babies Hospital locations. The LG Hospital POLST policy can be found on the LGH Intranet, and POLST forms are available on all nursing units. In addition, care management and social work services are available to assist physicians with completion of the POLST form.

POLST will not solve all end-of-life treatment issues. POLST will, however, assist health care providers to honor their patients’ wishes by clarifying treatment goals and minimizing confusion regarding treatment preferences as the patient moves from one treatment setting to another.

For more information on POLST please visit www.POLST.org or call Legal Services at Lancaster General Hospital.

Resources

1. Every human being of adult years and sound mind has a right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages. Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 129-30, 105 N.E. 92, 93 (1914). 20 Pa C.S. §§ 5422 through 5488 (2010).

2. Cruzan v Director, Missouri Director of Health, 497 US 261 (1990).

3. A living will is a document that expresses an individual’s wishes and instructions for health care when the individual is determined to be unable to make their own decisions. In Pennsylvania a living will is effective only when the individual is both incompetent and has an end stage medical condition or is permanently unconscious. 20 Pa. CS. 5422 (2010).

4. A health care power of attorney is a document in which an individual designates another individual to make health care decisions. 20 Pa. CS. 5422 (2010).

5. Hickman SE, Nelson CA, Perrin NA, et. al. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physicians orders for life-sustaining treatment program. J Amer Ger Soc. 2010;58:1241-1248.

6. www.POLST.org

7. The form can be accessed from the DOH website at www.health.state.pa.us. It has been given a position of prominence as one of the “Quick Links” that can be accessed from the top middle of the homepage.

8. Guidance for Health Care Professionals aging.upmc.com/professionals/resources-polst.html