March 24, 2016
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Inappropriate POLST use in skilled nursing facilities
by Dr. Tim Gieseke, CALTCM Vice President; Chair, Education Committee

At the recent national POLST meeting, a case of a resident unwilling to complete a POLST was discussed.  As most readers are probably aware, POLST is not generally recommended for residents unless they are in the last year or so of life.  In this case, in a nearby state, a SNF demanded that a total joint replacement resident with a good prognosis complete and sign the POLST as a condition of admission to the facility. When the resident refused, the facility refused to admit him.

In California, as in all states, completing a POLST is the resident’s choice and can’t be a condition of admission. Prior to the POLST, facilities met CMS’ mandate for determining advance care planning and goals of care status on all admissions by use of PIT (Preferred Intensity of Treatment) or PIC (Preferred Intensity of Care) forms. With the introduction of Section S (POLST reporting on section S for MDS) in California, many facilities seem to be under the mistaken impression that they are being graded by CMS or CDPH on how many POLSTs they do.

Certainly considering the advantages of the POLST as a document that more precisely supports advance care planning and the appearance of POLST on Section S, it’s no surprise that many of the facilities in my community have switched from PIT forms to having POLST forms as part of their admission package. While these facilities are aware that this is optional, and certainly would not refuse a resident admission because he would not sign a POLST, it does raise questions about whether some residents are inappropriately asked to complete a POLST as in the above case.

The practice of placing POLSTs in every resident’s admission paperwork has, on occasion, also resulted in POLSTs in charts that are signed by the physician with no choices indicated and no signature by the resident or durable power of attorney. If that occurred, even though the POLST isn’t valid (Section A choice and both signatures needed), the law says that by default, the resident has chosen Attempt CPR and Full Treatment status. But what is more concerning is that a physician would sign a document that has life-and-death implications without taking the time to determine what the resident (or surrogate) would want—it’s basically like signing a blank check.

Many facilities do not have a policy and procedure for the use of POLST. For those who need one, there is a model policy for SNFs available at no charge on the Coalition for Compassionate Care of California website.

To clear up the potential for confusion, CALTCM, CAHF, and the Coalition for Compassionate Care of California are committed to working with the CDPH. We're hoping to create an All-Facilities Letter that will provide a reminder, and clearer guidance, on the voluntary nature of POLST.

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