Until now, a person could implement an Advance Directive to state what their wishes would be at the end of their life. An Advance Directive generally contains information about a person’s desire to be mechanically ventilated, artificially fed, and his desire for comfort care. However, an Advance Directive does little to protect a person from unwanted emergency medical care like CPR or transfer to a hospital. A person would need to have a separate Do Not Resuscitate Order (DNR) to protect him from unwanted chest compressions, electrical shocks, and artificial breathing.
With the use of a POLST paradigm, emergency and medical personnel have clear orders on which actions to take in the event of an emergency based on the patient’s wishes. It includes the patient’s desire to have or refuse CPR, to be taken to a hospital, and whether to receive artificial nutrition. The paradigm can follow a person wherever he goes; it’s valid at home, in a nursing home, a long-term care facility, and in the hospital.
What Does the POLST Include?
The POLST paradigm has three or four sections (depending on the state) in which a person can choose his or her desired medical intervention:
A person can choose to have cardiopulmonary resuscitation (CPR) attempted. Choosing this option means choosing “Full Treatment” in section B. Alternatively, a person can choose to “Allow Natural Death,” also known as Do Not Attempt Resuscitation.
- Medical Interventions
A person has three choices of the degree of medical interventions they would like. The first choice is “Comfort Measures Only” which means providing only care that would relieve pain and suffering. Choosing this option means that the person would only be transferred to a hospital if suffering couldn’t be relieved at home.
The second choice is “Limited Additional Interventions” which includes comfort care from the first choice but may also include intravenous (IV) fluids and antibiotics. There is an option to elect NOT to be transferred to a hospital unless suffering cannot be relieved at home.
The third choice is “Full Treatment.” Choosing this option means that the person wants comfort care, IV fluids, antibiotics, CPR, and all other intensive medical care including transfer to a hospital.
There is a line for in this section for any additional orders. Patients may decide with their physician to limit the type of IV medications used or might choose to be specific regarding the type of breathing support they want.
This section allows patients to determine when and if antibiotics should be used to treat infections.
- Artificially Administered Nutrition
This section allows a person to state their wishes about being fed artificially, typically through a nasogastric (NG) tube for short-term feeding or through a gastric tube (inserted through the skin into the stomach) for long-term feeding. The choices include “No artificial nutrition by tube,” which is pretty clear, “Defined trial period of artificial nutrition by tube” which usually means feeding artificially for a short time to see if there is improvement in their condition, or “Long-term artificial nutrition by tube” which would typically be done through a gastric tube.
How is the POLST Different than an Advance Directive?
An Advance Directive is designed to give instructions on desired medical interventions once a person has already had emergency treatment -- usually directed towards hospital or nursing home staff. The POLST is designed to instruct emergency personnel on what actions to take while you're still at home.
Who Needs to Sign a POLST?
In all states where the POLST is accepted and legal, a patient or their legal healthcare decision maker needs to sign the form. A physician must also certify that the decision the patient is making is consistent with his current medical condition. For example, if a healthy 30-something-year-old woman, such as myself, requested to Allow Natural Death, Comfort Measures Only, and No Artificial Nutrition, my physician would (hopefully) not sign the form. In some states, a nurse practioner (NP) or a physician’s assistant (PA) may legally sign the form.
Anyone who has a chronic or life-limiting illness or anyone with advanced age should consider having a POLST document. To find out if your state accepts and uses the POLST paradigm, visit the POLST website.