Having a POLST Form Can Be the Difference Between Life & Death… Literally
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Summary
Navigating end-of-life care can be daunting, but being informed can empower individuals to make decisions that align with their values and needs. In a conversation with Dr. Jeffrey Stoneberg, Medical Director of Palliative Care at Sutter Medical Center in Sacramento, we explore the importance of advance care planning and the role of POLST (Physician’s Orders for Life-Sustaining Treatment) forms.
The Importance of Advance Care Planning
Advance care planning involves preparing for situations where you may not be able to make healthcare decisions for yourself. It’s about retaining control over your medical care by expressing your preferences in advance. Dr. Stoneberg emphasizes that while Advance Directives are essential for everyone, POLST forms are not universally necessary. They cater specifically to individuals with medical conditions requiring specific intervention directives.
What is POLST?
POLST, or MOLST (Medical Orders for Life-Sustaining Treatment) in some states, forms are medical directives that specify the types of life-sustaining treatments a person wishes to receive or refuse. Unlike Advance Directives, they translate a patient’s wishes into physician orders and are recognized across medical settings, such as hospitals and nursing homes.
The Structure of a POLST Form
A POLST form is structured into three main sections:
- Resuscitation Orders: This section addresses whether CPR should be performed if a person’s heart stops. Dr. Stoneberg notes the importance of thoughtful consideration, as resuscitation can result in severe complications and doesn’t always lead to the desired outcomes.
- Medical Intervention Levels: Three options exist:
- Full Treatment: Intensive interventions to restore health.
- Selective Treatment: Limited interventions avoiding invasive measures like ventilators.
- Comfort-Focused Treatment: Prioritizing alleviation of discomfort over prolonging life.
- Artificial Nutrition: Decisions regarding short-term or long-term nutritional support through feeding tubes.
How POLST Works with Advance Directives
While Advance Directives designate decision-makers and outline desired medical interventions, POLST forms convey actionable medical orders based on these directives. Dr. Stoneberg points out that the two documents should align to avoid any contradictory signals that might complicate decision-making.
Scenarios for Using POLST
Dr. Stoneberg highlights scenarios where a POLST form would be beneficial:
- Advanced Illness: For those with significant medical conditions who wish to avoid aggressive treatments.
- Clear Directives in Emergencies: POLST forms are effective in specifying preferences when emergencies occur, like being readily accessible for first responders.
Implementing POLST and Advance Directives
The key takeaway from Dr. Stoneberg is to ensure that both the POLST and Advance Directives harmonize to reflect the patient’s wishes accurately. He advises involving family members and healthcare teams in these discussions to ensure clarity and preparedness for future health care decisions.
Conclusion
Understanding and utilizing advance care planning tools like POLST and Advance Directives can significantly impact the quality of medical care one receives in critical situations. With informed guidance from experts like Dr. Jeffrey Stoneberg, individuals can make empowered decisions that align with their values and health care goals.
FULL TRANSCRIPTION:
Kevin Berk: Thank you for joining us on the LightAtTheEnd.com Podcast. LightAtTheEnd.com is a resource for those who want to learn more about end of life topics, but don’t know where to start. I’m Kevin Berk and I’m joined again today by Dr. Jeff Stoneberg, Medical Director of Palliative Care at Sutter Medical Center in Sacramento.
And we’re talking about filling out a POLST form – Physician’s Orders for Life Sustaining Treatment – with your care team.
Jeff, thank you so much for joining me yet again. [It’s] great to have you here and, [I’m] glad to be covering this topic.
Understanding Advance Care Planning
Dr. Jeff Stoneberg: Sure. I’m, I’m, I’m honored to be here and talk to you again, Kevin. I think the greater context of what we’re talking about is really Advance Care Planning, which is the concept of how do we empower ourselves to maintain our own decision making process and our own control over our healthcare in situations where we may not be able to speak for ourselves. Again, Advance Directive is what do I want for my future care if something happens to me? What’s allowable for me in terms of my quality of life? What’s important to me to enhance my quality of life? What are situations that I know I may not want for myself? And who is gonna make decisions for me if I get really sick and I can’t make those decisions for myself? So the Advance Directive is really providing that framework of decision making so that I am insured to get the care that I want for myself.
A MOLST form or POLST form stands for Medical Orders for Life Sustaining Treatment or Physician’s Orders for Life Sustaining Treatment. They’re identical forms. MOLST versus POLST and in different states you’d have to look up which form your state might use, but they’re identical forms. And that is really a concept of if I drop to the floor right now, what do I want done to me? Do I want CPR and the resuscitation to try to bring my heart back if it stops, or do I not want that? It gives you the ability to designate different sort of levels of intensity of care that you would accept or not accept.
POLST vs. Advance Directive
And then a quick question about artificial nutrition or feeding tubes. And it’s that simple. There’s three sections on there. And what differentiates the POLST or MOLST from the Advance Directive is, once it’s completed, it’s signed by the [person] or the representative, and it is signed by the physician or nurse practitioner.
I think physician assistant can now sign them, but it becomes a physician’s order. And so for example, if 9 1 1 is called ,the EMTs arrive to your home, they are required by law to try to resuscitate somebody unless there’s something like this POLST form that says Do Not Resuscitate, signed by the physician, they will follow that.
Whenever somebody starts to want to limit interventions,and things that might be done to them from a medical standpoint, that’s where these forms become more and more important. They are intended for those with advanced illness, those who are infirm, to protect them from things that we might do to them that might cause harm, that might elevate their risk, in terms of adverse events. the forms are intended for that population. It doesn’t mean a whole lot for me [personally].
When to Consider a POLST Form
I have an Advance Directive, but I don’t have a POLST form, ’cause if I hit the ground right now, I have, good quality of life. I don’t have much in the way of medical problems. I’m highly functioning physically and I would want a chance at a longer life at this stage of my life.
If I were, 80 years old, just diagnosed with heart failure and kidney failure, and I’m in and outta the emergency room, and I don’t really like my quality of life in the direction that it’s going in, I’m not gonna want the same things at that stage of my life as I do right now. If I hit the floor here and I end up on life support somewhere, my Advance Directive is gonna tell my loved ones how to make decisions for me, but I want that opportunity to get better.
If I’m in that scenario with, multi-organ failure and becoming weaker and in firm and in and out of the hospital, I may not want those same things done to me, and that’s where the POLST form becomes most important.
So Jeff, I was just going to ask: you’ve indicated that the Advance Care directive is essentially important for everyone to have. But you’ve just said that you don’t actually recommend a POLST or a MOLST form for just anyone. You need to actually have a real medical necessity for that, for your physician to create one.
You don’t have to, is that correct? You don’t have to. I could have a POLST form. I could have one filled out for myself. It’s just not gonna provide much more information or much more help. A POLST form does not allow you to designate a decision maker, the Advance Directive does.
There’s actually a part of the POLST form that references the Advance Directive: is there Advance Directive that exists? Yes or no? When is it dated? Who’s the decision maker? It doesn’t give you the opportunity to say, I want my wife, my, my parent, my kid, or whomever to make decisions for me on the POLST form.
You have to have decision making capacity, or at least capacity enough to make that particular decision in order to designate a decision maker and have that documented, an Advance Directive. So you do have to have decision making capacity, meaning that I understand the question you’re asking me. I understand the options for answering that question. Most importantly, I understand the consequences or outcomes of each of those options, and show consistency in my decision making. If I can do those things, then I have the decision making capacity. I can complete an Advance Directive, I can sign it, I can have witnesses or have it notarized and it becomes a legal document.
If I don’t have that capacity… i’m confused, I have a stroke, or I have delirium, or if I can’t make those decisions for myself, I cannot complete an Advance Directive. A POLST form can be completed on my behalf, if I don’t have the ability to make my own decisions. And so if there is an Advance Directive that exists and decisions are being made to not do aggressive sort of interventions like resuscitation, and we wanna document that and make sure that I not be resuscitated in the event of my death and be allowed to die naturally, then I would hope that somebody would fill out a POLST form for me and have my decision maker sign it. because if I can’t make that decision myself, I can have a surrogate decision maker sign my POLST form and get those steps into place that are gonna protect me from the medical community doing things to me I don’t want.
To your point, though, a healthy young person, there’s really not a whole lot of utility for having a POLST form. Age is irrelevant. We have young people that are very sick, unfortunately. So it’s really based upon what’s appropriate and what does that person want at that stage in their life.
But it really is intended for those that are a little bit more infirm.
Kevin Berk: Okay. And you’ve indicated that, that the default basically, is that if an EMT arrives at your place and you don’t have a brightly colored POLST form attached to the refrigerator that the default is going to be, that they’re going to try to resuscitate you and do any life sustaining measures. Is that accurate?
Dr. Jeff Stoneberg: Yep. That’s correct.
Again, it becomes protective in situations where somebody may want to limit what’s done to them. The fact that, a POLST form can be signed by a patient’s representative is also really important. somebody going to a nursing facility… so many nursing facilities are required to address resuscitation status when they’re admitted to the nursing facility. Many of them use the POLST form to fulfill that requirement, which is totally fine, but i’m not entirely confident that every time somebody goes to a nursing home that the conversation that I’m having with them in the hospital is going to be as thoughtful, as patient, as inquisitive as the conversation that’s gonna happen when somebody’s being transferred from the hospital to the nursing home with a lot of confusion, with a lot of stress. That’s gonna be very different.
So I try my best if somebody says, I don’t wanna be resuscitated, just as an example. I do my very best to make sure that person has a POLST form that indicates that because they know those are their stated wishes, and I know the conversation that I had with them and their families. We completed the form, so that all that form has to do is just be handed to the folks at the nursing facility.
They don’t need to have a conversation, which is probably gonna be done in about five minutes, whereas the one I’m having in the hospital may take several visits for several hours. So it’s an important form, and we see it used in different ways in different settings. And it’s on bright pink paper as you mentioned, because it’s easily visible and we tell people to put it on the refrigerator if they have one, because that’s where the EMTs are trained to look for it.
Kevin Berk: And if you don’t wanna look at a bright pink piece of paper on your fridge, just fold it up, put in an envelope, mark POLST on it, stick it on the side of the fridge. Good point.
Filling Out the POLST Form
Dr. Jeff Stoneberg: There’s three main sections to the POLST form. part A is the simple question of do we, or do we not try to resuscitate somebody if their heart stops. It’s either yes, we’re going to do it or we’re not. There’s no middle ground in my opinion. So when we do resuscitation, we talk about CPR, where we push in somebody’s chest to get the heart moving blood. We talk about defibrillation, where we’re shocking them with electricity if needed, medicines to simulate the heart. And finally, a ventilator, which is a tube that goes down your mouth into your lungs, patched to a ventilator which breathes for you.
All these things are done at the same time. It’s violent. We break ribs, we puncture lungs. Outcomes result in either death or, survival, which could include kidney failure, liver failure, brain injury from lack of oxygen delivery to the brain. and a widely varying degree of recovery or lack thereof.
So resuscitation, like I said before, is not just like jump starting a dead car battery, the body just doesn’t jump back to life like the car does. We can get into situations that are untenable to a patient that can induce further suffering, that can be contrary to what they might want for themselves.
So the discussion about, do we try to resuscitate somebody or not, is complex. It’s based upon what their values are and what they want, and also common understanding of what their medical illness is. Somebody [who] has end stage heart failure and their heart is giving out. Well, when their heart stops, I’m not gonna be able to get that heart going again. There’s no way, it’s already failing. Somebody with, advanced cancer, for example, our success rate for resuscitation drops from mid 30 percentage range down to less than 5%. 5%, in terms of successful resuscitation. and a successful resuscitation is measured by the return of a heartbeat and the blood pressure. [It] doesn’t say anything that happens to the kidneys, the lungs, the liver, um, the brain. So you can have somebody that is resuscitated, it may have taken a half an hour and their heart’s beating again, but now their brain doesn’t work, and now they’re in a persistent vegetative state, never to wake up. They’re being kept alive by machines, by being fed through tubes. That’s a successful resuscitation. And so is that really what somebody’s looking for is their outcome? So that question of do we or do we not try to resuscitate is complex and very nuanced and has to be taken into account for each individual situation and values. But that’s really the first question on that form.
The second, question that we’re asked is in reference to medical interventions. And by this we mean what is acceptable for us to do in terms of how aggressive should we be with somebody’s care if they come to the hospital. The first option on there is full treatment.
Full treatment means basically, that we’re going to do everything that we can to restore somebody’s good health. That means things like dialysis, surgeries, life support machines, ICU level of care, and,everything under the sun that we have available in the hospital, we’re gonna try. That would be full treatment.
There’s three options in that category. The third option is comfort focused treatment. And comfort focused treatment would mean it’s the exact opposite of the exact opposite end of the spectrum. That basically means, Hey, I’m sick. I’m failing, my heart’s failing, my liver’s failing, kidneys, whatever my case may be, cancer, ALS… My body’s sick.I’m getting sicker. If I have to go into the hospital, I just want you to make me comfortable. Make sure I’m not in pain, make sure I’m not short of breath, take away my nausea. Don’t send me for a bunch of tests and studies. Don’t do surgeries. Don’t poke me with needles.
Just make me comfortable. That might be somebody who’s either on hospice or nearing hospice. But they’re really focused more on their comfort as the primary goal. So those are, you know, Full Treatment, and Comfort Focused Treatment, opposite ends of the spectrum. Then you have this big gray area in the middle called Selective Treatment.
Selective Treatment we recognize somebody’s sick, but they’re not at the end stages of their life. They’re not in the last, you know, weeks, months of life. They may be in the last several years of life, but they have medical challenges. They say, you know, I want you to… if I have a pneumonia, treat me with antibiotics. If I need oxygen or heart medications, treat those things. But if I get so sick that I need life support, the intensive care unit, I don’t want that. So we try to manage current illness and control it as best as possible. We try to treat reversible causes of illness to help somebody restore their health and feel better.
But we avoid putting sick, infirm, delicate people in intensive care unit situations where they’re on life support and likely never to get off. So we try to avoid harming, you know, reduce risk and maximize benefit as much as possible. so it’s this sort of the gray area. So for example, if somebody selects a Full Resuscitation in that first question, they must also be full treatment in the second section, because we cannot have any restrictions as to what we need to do in that situation. We need to do everything necessary to try to resuscitate you.
If somebody says, Do Not Resuscitate, that means if their heart stops, we’re not gonna try to restart it. If they select full treatment in the second question, that means if your heart stops, I’m not gonna resuscitate you. But if your lungs fail, maybe because you have COPD and you’re sick and you have pneumonia, and if your lungs are failing, but your heart is otherwise continuing to beat, if we need to give you some time on a ventilator to treat you with antibiotics and steroids, then we will do that.
So I could use a life support machine, a ventilator, because the heart’s never stopped. I don’t have to intervene with that, but it tells me that, hey, yes, this person wants aggressive treatment to restore their lung function, if we can, that could be potentially reversible. So, DNR Full Treatment means I’m not gonna try to restart your heart, but I will put you on a ventilator. I will use things like dialysis. when I go down to do not resuscitate and selective treatment, then I’m not gonna restart your heart if it stops. But I’m also not gonna put you on a ventilator. I’ll use oxygen, I’ll use oxygen masks, BiPAP machines, high flow oxygen machines, but I will not put you on a ventilator. So that draws a line.
So when you really look down into the nuances of this form, if you have somebody skilled that’s talking to you about it, you can really identify a lot of different scenarios on that form that are very helpful for the doctor or medical team to know what to do for somebody. The third question on that form is in regards to artificial nutrition. So would somebody want a feeding tube? My mom said no feeding tube so that we would fill out No Feeding Tube. A temporary or trial of artificial nutrition is one that would go through the nose down in the stomach, and then a more permanent feeding tube would go through the abdominal wall into the stomach.
These forms have to make sense. If somebody indicates a situation on the Advance Directive where there’s potential that they’re gonna end up on a ventilator, whether they’re full code or or that they check Full Treatment, then my suggestion is always a trial of artificial nutrition, because if I put a tube down your throat, you can’t eat or drink. I need to give you some nutrition during that time. And if you tell me no feeding tube, no artificial nutrition, that doesn’t make sense. The forms have to make sense to a large degree. and there are other… some other nuances in these forms too that are very helpful.
The Importance of Time-Limited Trials
If somebody checks Full Treatment, there’s also a box that says Trial of Full Treatment. And what that means is, I want you to do everything to save my life and to restore my health, but if I get stuck on machines and I’m not getting better, or if my health is not getting back to the point where I hope it to be and regain my independence, then I don’t want you to keep me in this situation and I want you to let me go.
So that’s what that trial means. So if we refer back to that earlier question about would a POLST form be helpful if, for somebody who, is, healthy. That’s one scenario where it would be very helpful. You could check Full Code, Full Resuscitation, Full Treatment, but then you can check that Trial of Full Treatment, which says basically, we’re not gonna keep you in a vegetative state or in some other level of health that requires you to be dependent on others in a nursing facility, if that’s not what you want.
So that would be one indication that would be helpful to have a POLST form in somebody who’s otherwise healthy.
Kevin Berk: Jeff, is that, is that trial a specific amount of time or is it just up to you know, whatever the medical professional feels is reasonable?
Dr. Jeff Stoneberg: Depends on the situation, and it is somewhat subjective in terms of what the family needs to have enough time that they feel is important.
Kevin Berk: Okay.
Dr. Jeff Stoneberg: a lot of times it’s the window of opportunity by which somebody’s put on a ventilator until the time they may need a tracheostomy, which is usually about 10 days to two weeks. Then that gives you that time to make some decisions in the middle. I’m always looking at the trend over time, so how is somebody doing over a period of time?
Are they getting better, staying the same, or getting worse? [If] somebody’s getting better, let’s continue to support their recovery. If they’re getting sicker and having more complications, we need to think about whether this is the right path. So that trial is literally a trial.
Kevin Berk: I had that same question for both the Advance Directive and the POLST form, which was,
if you were to approve of a time-limited something like, I’m okay with a feeding tube, but only for, I don’t know, 48 hours or 72 hours before I want that discontinued. Do you feel like there is a certain amount of time that…
Dr. Jeff Stoneberg: No.
Kevin Berk: …that you need to be able to say, you know, well, we’ve given this the best shot.
Dr. Jeff Stoneberg: So two, two thoughts on that. So you’re talking about what we call Time-Limited Trial, which I advocate for in many ways.
Many times, especially if there’s times of dissent where there’s one family member wants one thing, another wants another. Where a physician wants one treatment and another physician wants another, then to and say, let’s pick a, let’s pick a plan. Let’s try it. Let’s see what the result is. But we’re gonna have set limits on it.
And if we’re, if it’s effective, we’ll continue. If it’s not we’ll refocus. The time limited trial in terms of the length of time is either gonna be dependent upon how much time do we think is gonna be necessary for that treatment to work or show some effect. I don’t wanna make a decision before a treatment’s out of an ability to work.
another measurement of time is gonna be what does the family feel is necessary, as a reasonable amount of time? Strokes are a good example of that. If the family feels, you know, I need to have six months to see if you know this person’s gonna get better, or I need to have one month, then it’s gonna be different for each family. It’s also based upon what they’re told by other physicians in terms of what their expectations might be. The neurologist says to a family, it’s gonna take six months to see whether they can recover. I disagree with that statement because it’s probably gonna be six months before the ultimate overall result of that stroke. But between now and that six months, you’re gonna see a trend. You’re gonna see whether they’re improving or not. [If] somebody’s not making any progress over the first two months, three months… do I need another three to know that they’re not gonna make enough progress to get back to where they’re going to be or wanna be? No. So the time limit is dependent upon a couple different factors, but we always have to have enough time to see whether specific intervention’s gonna work or not.
Kevin Berk: I’m so glad you brought that up. That’s been something that I’ve been really curious about ever since I filled out one of these for myself. Yeah. sorry, the, I’m referring to the Advance Directive, obviously not the POLST form. but I had really wondered whether or not you need to get specific about 48 hours, 72 hours, a week, a month, whatever.
Dr. Jeff Stoneberg: No, and if somebody says, you know, I, I, I’ll, I’ll be willing to be on a ventilator, but only for 24 hours. It’s not all that common that we get somebody off a ventilator within 24 hours. Certainly it happens, but my suggestion is, let’s give it at least a little while if we’re gonna go down that pathway, let’s at least give it a few days to see if we can get a hold of whatever the problem is and get you feeling better and get you off of that machine, but by you’re saying, I only want it for 24 hours, that tells me that I’m not going to keep you on that machine.
Kevin Berk: I’m so, so glad that you explained that, that really changes things.
Conclusion and Final Thoughts
Dr. Jeff Stoneberg: And again,the POLST form is an actionable document, meaning that the medical team will follow it. It does not require a person to have decision making capacity.
You can have your surrogate decision makers either stated or otherwise recognized by the medical team as to who are we gonna recognize to help make decisions so that person can sign a POLST form.
So decisions can still be made on behalf of the patient but, again, like I said before, the POLST form and the advanced directive should be sending the same or similar message. They shouldn’t be contradicting each other.
Kevin Berk: Dr. Stoneberg, thank you so much again for being here and sharing your expertise with us. It’s so powerful to hear from, a medical professional such as yourself to, uh, help inform these incredibly important decisions.