POLST – The Final Advance Directive
The POLST form (Physician Orders for Life Sustaining Treatment) is a legal document designed to answer the question: “How do you want to live your life as you go through the process of dying?” This is a profound and important question, which makes it surprising that while 80% of patients would like to have this discussion with their doctors, only 25% of doctors are aware of this desire and the conversation only happens 17% of the time. (Jump to Lessons Learned)
Why the POLST conversation is THE conversation to request of your doctor.
The conventional medical model is one of “Diagnosis and Treatment Plan.” Nowhere in this model does it consider how treatment might differ if you have an end-of-life conversation focusing on what types of medical care you wish to receive. Discussing what you want with the right people, at the right time, turns the conventional medical model on its head. Now it becomes: Diagnosis, Prognosis, “Goals of Care” discussion for end-of-life, and Treatment Plan that reflects patients’ wishes for care.
Goals of Care Conversation
The “goals of care” conversation is between the patient or patient surrogate and their physician or advance practice nurse (APN). It should explain medical procedure options and provide a clear explanation of what it means to prolong life vs. promote comfort. For example, people feel they don’t want a loved one to be hungry. Once you understand that hunger in a body that is shutting down is reduced or non-existent, you can understand that a feeding tube can be counterproductive. Too much fluid can cause pain, it is a freeway for germs, and does nothing to prolong life.
If you or a loved one can reasonably be expected to die in six months to a year, if the person is frail, elderly, terminally ill, or a long-term care resident with a chronic illness, it is appropriate to start the goals of care conversation. It is not a onetime conversation, but in the end, everyone understands what the patient wants and does not want medically.
How is the POLST form different from other end of life documents?
The POLST form is a medical order that must be followed always, in all places. These actionable medical orders complement your Advance Directive and Living Will. Doctors that follow the directions of the POLST form in good faith are protected from liability by the POLST law itself, while doctors and others that willingly ignore POLST directions will face consequences, both legal and professional. Unlike the Advance Directive the POLST form does not require the patient to have lost their decision-making process. There is no age limit on the POLST and it applies immediately. Unlike the DNR, the POLST form is portable across settings.
Filling out the NJ POLST form
- The official NJ form is on green paper, but white paper and copies of POLST are still legal documents
- Make sure the intent is consistent across all boxes. For example, marking “symptom treatment only” is inconsistent with saying you want to be resuscitated.
- Fill out the POLST form COMPLETELY with a doctor or Advanced practice nurse (APN), not a social worker. If a section is left incomplete, the full treatment will be given for that box.
- The form is invalid if it is not signed and dated by the patient or surrogate AND the Physician or APN
- This document is transferable to other states by custom. There is formal reciprocity between New Jersey and its contiguous states.
Lessons Learned:
In New Jersey, the POLST law passed in 2011 and yet, NJ spends more money than ANY other state in the country on end-of-life care.
- As of 2016, Doctors and Advance Practice Nurses can get reimbursed for having the end-of-life conversation with patients.
- NJ is the only state with a “Goals of Care” box on the POLST form.
- The POLST form is like a prescription. A hospital must legally accept a copy. The copy does not have to be notarized. But it MUST be legible. If the copy is bad, it may not be followed because it is not clear.
- It can be changed at any time, but changes require that the physician or AP nurse sign, date and time the voided document, then fill out a new one
- If a patient has decision-making capacity at the time he/she completes a POLST, he/she can indicate that he permits his surrogate to amend any or all parts of an existing POLST form when the patient may no longer have decision-making capacity — provided the new, revised POLST is properly completed, including signature by a physician or APN.
- NJHA is piloting a secure database to receive individual POLST forms
Disclaimer: The material in this blog is for educational purposes only. It is not intended to replace, nor does it replace, consulting with a physician, lawyer, accountant, financial planner or other qualified professional.
With thanks to my collaboration partner Jon Sugarman, BSN, MSN – Adult/Geriatric Care, DPN, Certificate, Psychiatric/Mental Health Nursing
Jon’s work in every setting is based on his mission: “to improve and protect the health of older patients for the purpose of maximizing the quality of their lives.”
