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
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