|POLST – A Step Forward in Advanced Directives and Achieving the Triple Aim|
|Kelly Hardee-Wheeler, MHA, Health Systems Specialist, Enhanced Multi-Service Market Office, Tripler Army Medical Center|
Healthcare professionals at the University of Oregon recognized the limitations of traditional healthcare advanced directives, including living wills and the appointments of medical proxies in the early 1990s, which gave birth to the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program (POLST). These professionals recognized physicians needed to be more involved in discussing end-of-life care with their patients and translating patient preferences into medical orders that would be adhered to in an emergent event. POLST is a medical order that tells others your wishes for life sustaining treatments and used by people who have a serious health condition (Bomba et al., 2012). In Hawaii, the orders on the POLST form are legal and are followed by parametics and other healthcare providers across the entire state. POLST requires a signature of the doctor, the patient, and the patients’ or patients’ identified representative, such as someone with healthcare power of attorney or a surrogate decision maker. It should be used if you have a serious health condition and you want to make decisions about life-sustaining treatment. The doctor can use the POLST form to write clear and specific medical orders regarding the patients’ medical condition and their preferences for medical treatments including: 1) attempt cardiopulmonary resuscitation (CPR), 2) administer antibiotics and IV fluids, 3) hospitalization, 4) use of a ventilator, 5) use of a feeding tube, and 6) preference for comfort care (Kokua Mau, 2009).
The implementation of POLST creates the opportunity to improve the experience of care including the quality of care and quality of life for those with serious health conditions in addition to reducing per capita cost, in particular, end-of-life healthcare costs. With the promulgation of patient-centered care throughout healthcare organizations as a basis for improving quality, the adoption of POLST is a means by which to make care and medical decision making at the end-of-life more patient-centered and preserve patient autonomy. Living wills are general statements of a patients’ preference and still require medical orders requiring further interpretation by the medical proxy or healthcare professionals. Likewise, the healthcare proxy, has been found to incorrectly predict a patients’ end of life wishes (Shalowitz et al., 2006) or it is difficult for the family member to act on those wishes (Krieger, 2012). As quoted by a bioethicist of the Hastings Center, “What medicine provides is more and more ways to keep people going…an extra few days or a month—it is very, very hard for doctors and families to give that up” (Krieger, Lisa, 2012). Studies are finding that in states with POLST programs, patients’ preferences were by in large adhered to. A National Institute for Health study (Hickman et al., 2010) found that nursing home residents who used a POLST form to indicate their preference for comfort care only were 59 percent less likely to receive life-sustaining medical interventions that were not requested, when compared to residents with DNR orders, suggesting that POLST promotes closer adherence to documented treatment preferences than DNR orders. Additionally, findings from other studies of POLST programs indicate that “patients’ values are accurately reflected in the orders, that the orders are followed by first responders, that life-sustaining treatment orders beyond CPR are useful to guide care consistent with the patient’s wishes, and that implementation can evolve to become a standard of care in a community, region, or state”(Citko et al, 2010).
The Institute of Medicine (IOM) report, Approaching Death: Improving Care at the End of Life (Field & Cassel, 1997) stated, too many people suffer needlessly at the end of life, both from errors of omission and from errors of commission. There are problems of under-treatment but the counterpoint is aggressive treatment that prolongs and even dishonors the period of dying. Care for dying patients is in considerable proportion covered by Medicare or Medicaid programs; 30% of Medicare expenditures are attributable to the 5% of beneficiaries who die each year and approximately one third of the expenditures in the last year of life are spent in the last month (Zhang B, Wright AA, Huskamp HA, & et al, 2009). Several studies have found that there are lower medical costs in the final week of life as well as in the last six months of life when the patient had end-of-life discussions with physicians, in particular for cancer and chronic heart failure diagnoses. Lower costs resulted due to a more limited use of intensive interventions (Zhang et al., 2009).
The Military Health System has a fourth aim, Readiness, at the center of its mission. My husband and I often get into the discussion of what would we do if his mother was hospitalized or required a higher level of care than what she currently receives. You see, she is a diabetic who three years ago began dialysis and who has no known advanced directives in place. Like our civilian counterparts, it is close family members, sons and daughters, who become the medical proxies for our aging parents and family members. Part of being ready and resilient is mental preparedness. Having a tool such as POLST is a good starting platform for discussion and mental preparedness for dealing with our aging loved ones. I know from personal experience with the death of my father several years ago, that having discussed everything from medical intervention to preparing all things necessary financially and spiritually reduced our stress and gave our family peace knowing we did things the way that he wanted.
The IOM report defines a good death as “one that is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients’ and families’ wishes; and reasonably consistent with clinical, cultural, and ethical standards” (Field & Cassel, 1997). The POLST programs placed into law or being developed in currently 47 states is another step forward for advanced directives that is in alignment with the IHI Triple Aim by improving the experience of care and reducing healthcare costs, and has the potential to improve the readiness and resiliency of families in the Military Health System which have loved ones facing terminal illnesses. As healthcare executives, we are charged with addressing ethical issues and care issues surrounding death and dying as well as promoting public dialogue that will lead to awareness and understanding of end-of-life concerns (American College of Healthcare Executives, 2009). The POLST program and the form, is a tool that can facilitate conversations on end-of-life decisions, making something that can be very difficult, just a little bit easier for executives, healthcare providers, patients, and families.
More information about POLST in Hawaii can be found at http://www.kokuamau.org/professionals/polst and more information and research about the National POLST Paradigm Program can be found at http://www.polst.org/
Agency for Healthcare Research and Quality. (2001). Improving the health care of older americans. Rockville, MD. Retrieved from http://www.ahrq.gov/research/findings/final-reports/olderam/index.html
American College of Healthcare Executives. (2009). Decisions near the end of life policy statement. Retrieved from https://www.ache.org/policy/endoflif.cfm
Bomba, P., Kemp, M., & Black, J. (2012). POLST: An improvement over traditional advance directives. Cleveland Clinic Journal of Medicine, 79(7), 457–464. doi:10.3949/ccjm.79a.11098
Citko, J., Moss, A., Carley, M., & Tolle, S. (2010). The National POLST paradigm initiative, 2nd Edition. Retrieved from http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_178.htm
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Hickman, S., Nelson, C., Perrin, N., Moss, A., Hammes, B., & Tolle, S. (2010). A Comparison of methods to communicate treatment preferences in nursing facilities: Traditional practices versus the physician orders for life-sustaining treatment program. Journal of the American Geriatrics Society, 58(7), 1241–1248. doi:10.1111/j.1532-5415.2010.02955.x
Institute of Healthcare Improvement. (2014). The IHI triple aim. Retrieved from http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx
Kokua Mau. (2009). POLST. Retrieved from http://www.kokuamau.org/professionals/polst
Krieger, Lisa. (2012, February 5). The cost of dying: It’s hard to reject care even as costs soar. Mercury News. Retrieved from http://www.mercurynews.com/cost-of-dying/ci_19898736?source=pkg
Shalowitz, D., Garrett-Mayer, E., & Wendler, D. (2006). The accuracy of surrogate decision makers: A systematic review. Archives of Internal Medicine, 166(5), 493–497. doi:10.1001/archinte.166.5.493
Zhang B, Wright AA, Huskamp HA, & et al. (2009). Health care costs in the last week of life: Associations with end-of-life conversations. Archives of Internal Medicine, 169(5), 480–488. doi:10.1001/archinternmed.2008.587