Quick Reference Guide on POLST for Physicians, Nurse Practitioners, and Physician Assistants

Download POLST Quick Reference Guide for Physicians [PDF]

Background

POLST is the acronym for Physician Orders for Life-Sustaining Treatment. POLST helps give seriously ill patients more control over the medical treatment they receive. The POLST form guides discussions between patients, their loved ones, their providers, and their healthcare team about treatment wishes during serious illness. POLST transforms those wishes into medical orders, which are actionable and must be respected across the continuum of healthcare settings. Research shows that POLST helps to ensure patients receive the treatments they want and do not receive treatments they do not want.

POLST should not be introduced as a discussion about end-of-life care. POLST should be introduced as a discussion about possible serious illness.

POLST Is Always Voluntary for Patients but Must Be Honored by Healthcare Providers

Filling out a POLST form is completely voluntary for patients. However, California law requires that the medical orders in a valid, completed POLST be honored by healthcare professionals and provides immunity from civil or criminal liability to those who comply in good faith with a patient’s POLST requests.

There are two situations in which a healthcare professional is allowed to not honor POLST orders:

  • If the form is invalid because it lacks the provider’s signature, the patient’s or legally recognized decision maker’s signature, or a selection in Section A.
  • If the treatment choices selected are medically ineffective or contrary to the standards of medical care applicable to the provider.

In the latter case, the provider may consult with the patient or their loved ones and determine a more appropriate set of choices that are still aligned with the patient’s goals and obtain a signature on a new POLST from the patient or their legally recognized decision maker.

POLST and the Advance Healthcare Directive

POLST complements an advance healthcare directive (AHCD) and is not intended to replace that document. An AHCD is still necessary to appoint a legally recognized decision maker and is recommended for all adults, regardless of their health status. When filling out a POLST, providers should confirm whether the patient has an AHCD and, if so, obtain a copy of the AHCD and review it. If the AHCD and POLST call for different medical treatments, the provider should confirm the patient’s current wishes regarding medical treatment and then assist with completing new, up-to-date documents. Until a new document is completed, the provider should be guided by the patient’s most recently documented wishes.

Completing and Signing the POLST Form

A POLST form can be completed and signed by any physician, nurse practitioner (NP), or physician assistant (PA) who has a treating relationship with the patient. This includes the primary care provider, consulting providers, hospitalists, providers caring for the patient in a nursing home, and emergency department providers, etc. Knowledge of the patient’s medical condition, prognosis, and capacity to make decisions is required, as well as a willingness to have an informed, collaborative discussion with the patient and/or their healthcare decision maker.

Billing for Completing a POLST Form

Medicare and Medi-Cal pay healthcare providers for advance care planning (ACP) discussions with beneficiaries under CPT codes 99497 and 99498. Authorization for Medicare payment was set forth in the November 2015 Final Rule, published by the Centers for Medicare and Medicaid Services (CMS). Information on Medi-Cal rates is published by the California Department of Health Care Services.

Initially, in order to be billable under Medicare, ACP discussions had to be face-to-face conversations with Medicare patients and/or their surrogates (the patient does not need be present), to cover the patient’s specific health conditions, their options for care and what care best fits their personal wishes, and the importance of sharing those wishes in the form of a written document. On April 30, 2020, CMS expanded Medicare billing flexibilities for virtual encounters in response to the COVID-19 pandemic. This expansion has been made permanent.

The CPT manual defines an AHCD as a document appointing a healthcare agent and/or recording the wishes of a patient pertaining to their medical treatment at a future time should they lack decisional capacity at that time. Relevant legal forms differ from state to state. The POLST form qualifies as a relevant legal form under this definition.

POLST for Patients Lacking Capacity

A healthcare professional can complete the POLST form based on family members’ understanding of their loved one’s wishes. The legally recognized decision maker can then sign the POLST form on behalf of the patient. A legally recognized decision maker may be any one of the following:

• Parent or legal guardian of a minor patient

• Healthcare agent appointed in an AHCD or medical power of attorney

• Surrogate verbally designated by the patient with capacity at the place of care

• Surrogate selected by the provider according to California law and facility policy

• Conservator or guardian with authority to make healthcare decisions

“Next of kin” or family members of a patient are not automatically legal decision makers.

SNF Patients Lacking Capacity and Any Legally Recognized Decision Maker

If the patient lacks capacity and has no known legally recognized decision maker and resides in a skilled or intermediate care facility, POLST decisions can be made by the facility IDT with input from a person appointed by the Office of the Long-Term Care Patient Representative (OLTCPR). Once the IDT and patient representative reach consensus on treatment choices, the POLST can be signed by SNF staff on behalf of the IDT.

Modifying a POLST Form

The POLST can be modified or revoked by a patient, verbally or in writing, at any time. Changes may also be suggested by a physician/NP/PA or requested by a patient’s decision maker, based on new information or changes in the patient’s condition. Changes made without the patient’s input should be discussed and agreed upon by the provider and the patient’s decision maker. Any changes should be consistent with the patient’s known goals of care or in their best interests.

CPR/Full Treatment Requirement

Cardiopulmonary resuscitation (CPR) is defined to include chest compressions and advanced cardiac life support (ACLS) procedures, including intubation. If CPR is desired, then the full array of ACLS procedures should be expected to be implemented. If CPR is successful initially and return of spontaneous circulation (ROSC) is achieved, then it is highly likely that the patient will require a ventilator and other intensive care. A patient not willing to accept Full Treatment including ventilator treatment should not choose to have CPR performed. The patient can choose Full Treatment as a Trial Period past which life support would be withdrawn if the patient is not expected to recover. Section B: Medical Interventions

Choices in this section include:

• Full Treatment: Primary goal of prolonging life by all medically effective means

• Selective Treatment: Goal of treating medical conditions while avoiding burdensome measures

• Comfort-Focused Treatment: Primary goal of maximizing comfort

Full Treatment

This is the appropriate selection for patients who wish to receive all available treatments designed to prolong life, including invasive medical procedures, such as in an intensive care unit (ICU) or major surgery. As noted above, a patient may choose Full Treatment AND Do Not Attempt Resuscitation/DNR. Comfort measures to relieve pain, address symptoms, and increase comfort are also part of Full Treatment.

Selective Treatment

This medical intervention is the most complex category of treatment choices to understand.

Patients choosing this treatment category generally are asking not to be treated with invasive medical procedures, such as mechanical ventilators, and major surgery, such as open-heart surgery. However, ICU care is not strictly prohibited. For instance, a patient who has chosen Selective Treatment could conceivably be treated in the ICU with intravenous vasopressors if transiently hypotensive, or with bi-level positive airway pressure (BiPAP) or similar respiratory interventions short of intubation if such treatment is consistent with the patient’s goals of care. Similarly, surgery is not prohibited. Consider the case of acute cholecystitis: Cholecystectomy may be an option if it can be performed with relative ease and low risk.

The common thread as to what is considered Selective Treatment is based on an assessment of the balance between risks, benefits, and burdens according to the patient’s goals. Patients who choose Selective Treatment are often communicating that they do not want treatment that has a low chance of success or will result in prolonged, difficult, uncertain recovery phases. Comfort measures to relieve pain, address symptoms, and increase comfort are also part of Selective Treatment.

Comfort-Focused Treatment

This is an appropriate selection when patients wish to forego treatments for acute, potentially treatable illnesses (i.e., pneumonia) in favor of treatments focused on relieving pain and distress and providing comfort. Comfort measures may include treatment other than medication. For example, in the case of a hip fracture, an operation is often performed to relieve pain. Without an operation, the patient with a fractured hip would likely have to endure prolonged and inadequately treated pain. Spiritual and psychosocial issues are important to be addressed.

Palliative care teams often include chaplains and social workers to help with these needs. Comfort measures are always included in all treatment options.

Artificially Administered Nutrition

Feeding tubes and enteral nutrition are best discussed with patients using the terminology of “medically prescribed nutrition” or “artificial nutrition.” This terminology emphasizes that enteral feeding is a medical treatment that has potential benefits and potential risks and can be accepted or refused like other medical treatments.

Artificial nutrition has been shown to be beneficial in some very well-defined situations, including head and neck cancers and neurologic syndromes that disproportionately cause dysphagia. There are other situations where no benefit from providing artificial nutrition has been shown; for instance, for patients with advanced dementia or those actively dying from terminal illness. There are definite risks associated with enteral feedings in these situations, including infection, aspiration, and fluid overload. Artificial nutrition does not generally enhance comfort to a terminally ill patient.

The studies that are available suggest that most dying patients do not experience hunger pains. In the last days to weeks of life, many patients may force themselves to eat just to please their loved ones. Their bodies and intestinal systems cannot accept usual amounts of food and water. Artificial nutrition or fluids given by feeding tubes or intravenous lines often cause discomfort in dying patients, including nausea or abdominal pain. In the last days and hours of life, as the body is shutting down, food and fluids are not absorbed or metabolized. Administering fluids by tube or IV at this time may increase swelling and lung congestion and cause additional discomfort to the patient.

 

Copyright © 2018, revised 2024, Coalition for Compassionate Care of California.  All rights reserved.

For permission to reproduce, contact info@coalitionccc.org.