TR AN SITION S Issues in palliative and end-of-life care
Using POLST to ensure patients’ treatment preferences By Harleah G. Buck, PhD, RN, CHPN, and Beth Fahlberg, PhD, MN, BS, RN
“WALT,” 80, WAS A RETIRED building contractor with advanced chronic obstructive pulmonary disease (COPD) and heart failure who lived alone in his own house. He had no family and few friends. As his illnesses progressed, he was hospitalized repeatedly. After discussing his poor prognosis with his healthcare provider, Walt drew up a living will that firmly expressed his desire not to undergo CPR or receive mechanical ventilation when his condition deteriorated. Several weeks later, a neighbor found Walt unresponsive on his kitchen floor and called 911. The paramedics who responded endotracheally intubated him for respiratory failure and provided fluid resuscitation during his transport to the hospital. Admitted to the ICU, Walt was diagnosed with acute kidney injury. He also had multiple pressure ulcers, some stage III and IV. Walt couldn’t be weaned from the mechanical ventilator, despite many attempts. Never fully regaining consciousness, he was unable to communicate or make decisions for himself. Because he had no family and no healthcare proxy, he had no one to make decisions for him. Because Walt’s condition was considered terminal, the hospital ethics committee recommended withdrawal of life support. This took place many days after his admission to ICU. Why did this happen when the patient had drawn up a living will clearly stating his wish to forego resuscitation 16 l Nursing2014 l March
and mechanical ventilation if he became unable to speak for himself? More importantly, how could this have been prevented? Using POLST to document patient preferences Research has shown that patients with advanced illness who use portable (sometimes called physician) orders for life-sustaining treatments (POLST) to specify their resuscitation preferences are more likely to have care consistent with their wishes than those who simply
Nurses who don’t routinely work with hospice patients may be unfamiliar with using POLST to ensure that emergency care in the community will be consistent with the patient’s wishes.
have an advance directive such as a living will.1 The POLST form provides standing medical orders that nurses, paramedics, and other first responders can act on immediately when the patient is in crisis, wherever the patient is—at home, in a clinic, or in the hospital. Covering the patient’s preferences concerning CPR, antibiotics, mechanical ventilation, and artificial nutrition, POLST has been shown to be more
effective than traditional advance directives at converting treatment preferences into immediately actionable medical orders and in limiting unwanted life-sustaining treatments.2 Without a POLST form, emergency responders are required to provide all appropriate medical interventions. For this reason, the brightly colored POLST form should be displayed in a prominent place in the home, such as on a refrigerator, where emergency responders will see it.3 POLST programs aren’t available in every state. For more information on how POLST differs from advance directives and on the availability of POLST in your state, visit http://www. polst.org. Ethical concerns Recently, POLST has been at the forefront of religious and ethical debate. At issue is a belief that these documents may be used in ways that are inappropriate or in ways that conflict with religious beliefs and ethical principles. Objections to POLST include concerns that orders may be implemented for patients who aren’t terminally ill, that they can be implemented by nonphysician healthcare workers, and that the checklist format is too simplistic for complex decisionmaking.4 Those of us working closely with patients and families struggling with the burden and uncertainty of advanced illness are often caught in www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the crosshairs of these issues. We’re all used to the idea that our patients must be asked about their advance directives on admission to an acute care facility. But nurses who don’t routinely work with hospice patients may be unfamiliar with using POLST to ensure that emergency care in the community will be consistent with the patient’s wishes. What can we as nurses do to ensure that the wishes of our patients with advanced illness are carried out after they leave the hospital in a way that’s ethically appropriate? • Become familiar with various ways to communicate patient wishes across settings. For instance, in many
www.Nursing2014.com
states, a DNR bracelet can alert emergency providers about the patient’s DNR status. • Ensure that nurses or others facilitating discussions with patients do so in collaboration with the patient’s primary providers. • Examine advance directive or POLST forms valid in your state and advocate for policies and processes that will ensure that ethical concerns are addressed and patients’ wishes for end-of-life care are honored. ■ REFERENCES 1. Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician
orders for life-sustaining treatment program. J Am Geriatr Soc. 2010;58(7):1241-1248. 2. Hickman SE, Sabatino CP, Moss AH, Nester JW. The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation. J Law Med Ethics. 2008;36(1):119-140. 3. POLST: National physician orders for life sustaining treatment paradigm. http://www. polst.org. 4. Brugger EL, Pavela SL, Toffler WL, Smith F. POLST and Catholic health care: are the two compatible? Ethics & Medics. 2012; 37(1). http:// www.cathmed.org/assets/files/Franklin, Brugger, POLST, E&M, Jan. 2012.pdf. Harleah G. Buck, a board-certified hospice and palliative care nurse, is currently an assistant professor at the School of Nursing, Pennsylvania State University, University Park, Pa. She was formerly a nurse at The Hospice of the Florida Suncoast in Largo, Fla. Beth Fahlberg is a clinical associate professor at the University of Wisconsin-Madison School of Nursing. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000443322.11726.91
March l Nursing2014 l 17
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Using POLST to ensure patients’ treatment preferences By Harleah G. Buck, PhD, RN, CHPN, and Beth Fahlberg, PhD, MN, BS, RN
“WALT,” 80, WAS A RETIRED building contractor with advanced chronic obstructive pulmonary disease (COPD) and heart failure who lived alone in his own house. He had no family and few friends. As his illnesses progressed, he was hospitalized repeatedly. After discussing his poor prognosis with his healthcare provider, Walt drew up a living will that firmly expressed his desire not to undergo CPR or receive mechanical ventilation when his condition deteriorated. Several weeks later, a neighbor found Walt unresponsive on his kitchen floor and called 911. The paramedics who responded endotracheally intubated him for respiratory failure and provided fluid resuscitation during his transport to the hospital. Admitted to the ICU, Walt was diagnosed with acute kidney injury. He also had multiple pressure ulcers, some stage III and IV. Walt couldn’t be weaned from the mechanical ventilator, despite many attempts. Never fully regaining consciousness, he was unable to communicate or make decisions for himself. Because he had no family and no healthcare proxy, he had no one to make decisions for him. Because Walt’s condition was considered terminal, the hospital ethics committee recommended withdrawal of life support. This took place many days after his admission to ICU. Why did this happen when the patient had drawn up a living will clearly stating his wish to forego resuscitation 16 l Nursing2014 l March
and mechanical ventilation if he became unable to speak for himself? More importantly, how could this have been prevented? Using POLST to document patient preferences Research has shown that patients with advanced illness who use portable (sometimes called physician) orders for life-sustaining treatments (POLST) to specify their resuscitation preferences are more likely to have care consistent with their wishes than those who simply
Nurses who don’t routinely work with hospice patients may be unfamiliar with using POLST to ensure that emergency care in the community will be consistent with the patient’s wishes.
have an advance directive such as a living will.1 The POLST form provides standing medical orders that nurses, paramedics, and other first responders can act on immediately when the patient is in crisis, wherever the patient is—at home, in a clinic, or in the hospital. Covering the patient’s preferences concerning CPR, antibiotics, mechanical ventilation, and artificial nutrition, POLST has been shown to be more
effective than traditional advance directives at converting treatment preferences into immediately actionable medical orders and in limiting unwanted life-sustaining treatments.2 Without a POLST form, emergency responders are required to provide all appropriate medical interventions. For this reason, the brightly colored POLST form should be displayed in a prominent place in the home, such as on a refrigerator, where emergency responders will see it.3 POLST programs aren’t available in every state. For more information on how POLST differs from advance directives and on the availability of POLST in your state, visit http://www. polst.org. Ethical concerns Recently, POLST has been at the forefront of religious and ethical debate. At issue is a belief that these documents may be used in ways that are inappropriate or in ways that conflict with religious beliefs and ethical principles. Objections to POLST include concerns that orders may be implemented for patients who aren’t terminally ill, that they can be implemented by nonphysician healthcare workers, and that the checklist format is too simplistic for complex decisionmaking.4 Those of us working closely with patients and families struggling with the burden and uncertainty of advanced illness are often caught in www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the crosshairs of these issues. We’re all used to the idea that our patients must be asked about their advance directives on admission to an acute care facility. But nurses who don’t routinely work with hospice patients may be unfamiliar with using POLST to ensure that emergency care in the community will be consistent with the patient’s wishes. What can we as nurses do to ensure that the wishes of our patients with advanced illness are carried out after they leave the hospital in a way that’s ethically appropriate? • Become familiar with various ways to communicate patient wishes across settings. For instance, in many
www.Nursing2014.com
states, a DNR bracelet can alert emergency providers about the patient’s DNR status. • Ensure that nurses or others facilitating discussions with patients do so in collaboration with the patient’s primary providers. • Examine advance directive or POLST forms valid in your state and advocate for policies and processes that will ensure that ethical concerns are addressed and patients’ wishes for end-of-life care are honored. ■ REFERENCES 1. Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician
orders for life-sustaining treatment program. J Am Geriatr Soc. 2010;58(7):1241-1248. 2. Hickman SE, Sabatino CP, Moss AH, Nester JW. The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation. J Law Med Ethics. 2008;36(1):119-140. 3. POLST: National physician orders for life sustaining treatment paradigm. http://www. polst.org. 4. Brugger EL, Pavela SL, Toffler WL, Smith F. POLST and Catholic health care: are the two compatible? Ethics & Medics. 2012; 37(1). http:// www.cathmed.org/assets/files/Franklin, Brugger, POLST, E&M, Jan. 2012.pdf. Harleah G. Buck, a board-certified hospice and palliative care nurse, is currently an assistant professor at the School of Nursing, Pennsylvania State University, University Park, Pa. She was formerly a nurse at The Hospice of the Florida Suncoast in Largo, Fla. Beth Fahlberg is a clinical associate professor at the University of Wisconsin-Madison School of Nursing. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000443322.11726.91
March l Nursing2014 l 17
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
