POLSTs (Physician Orders for Life-Sustaining Treatment), also known by related names, and DNR (Do Not Resuscitate) orders, should not be viewed as advance directives, even if one or both orders are defined that way by some states. POLSTs and DNRs are orders by a physician/clinician that apply, usually in the last year of life expectancy, for patients with serious progressive diseases or medical conditions. Nevertheless, the patient or surrogate should approve POLSTs, much the way a patient or surrogate should approve a DNR order issued by a clinician. The failure to get the patient’s or surrogate’s approval is certainly unethical, and perhaps should be illegal.
A DNR order means that cardiopulmonary resuscitation (CPR) should not be attempted if a person’s heart or breathing stops. It does not mean that other treatment should be reduced or discontinued, yet there is some evidence that this occurs. DNR orders are included in a POLST, if appropriate.
DNR orders and advance directives both began to be widely used in the 1970s. To diminish confusion, it is helpful to think of advance directives as documents completed by individuals, expressing their decisions about end-of-life health care and naming an agent or surrogate to speak for them if and when they cannot do so for themselves. Clinicians may be consulted by the patient about advance directives, but do not have to approve them. However, clinicians may not legally ignore them later, if and when an individual loses decision-making capacity. If clinicians refuse to honor advance directives, they should refer patients to other clinicians who do not object to the patient’s decisions.
POLSTs first came into use in the US nearly 30 years ago in Oregon, where they were used with seriously chronically ill patients who had progressive conditions, and their use has spread slowly to other states. They may also be used, at a clinician’s direction, by anyone who wishes to control their medical care preferences near the end of life.
Generally, issuing a POLST requires three steps:
1. The treating clinician and the patient, or the patient’s health care agent (surrogate) should have a discussion about the primary options available for end-of-life treatment. They should determine the wishes of the patient given the patient’s medical condition and discuss the available treatment options with reference to the patient’s advance directive or other known wishes.
2. The clinician then writes up the decisions on a visually distinctive form–usually, on a unique color of paper (see the example above). The form is kept at the front of the patient’s medical record or with the patient at home, so that it can be readily found. The orders are reviewed periodically, as needed. Typically, the form includes the most common medical issues a seriously chronically ill patient might face, including cardiopulmonary resuscitation, the level of medical intervention desired in the event of emergency (comfort only/do not hospitalize, limited, or full treatment), the use of artificial nutrition and hydration, and perhaps the use of antibiotics and ventilation.
3. To promote the continuity of care in decision making, clinicians must arrange for the POLST form to travel with patients whenever they move from one place to another. Continuity of care also requires that the form be recognized by all medical professionals wherever the patient may be.
A POLST can be best understood as a medical care order that implements the patient’s decisions, some of which may be expressed in advance directives if the patient is unable to communicate at the time. It consolidates the medical treatment plan for seriously ill patients in one prominent document. Research in Oregon shows that POLST has had “positive outcomes in preventing unwanted resuscitations by emergency medical personnel, encouraging conversations about treatment preferences, and making the patient’s preferences for treatment limitations known and respected.”
Unlike DNR orders and “out-of-hospital do-not-resuscitate” (OOH-DNR) orders, POLSTs cover a broad range of treatment decisions, from full treatment to comfort care only. They focus on more immediate medical decision making, rather than distant planning.
A benefit of using POLSTs is that the practice can be implemented through a state law or outside any law, where none exists, based on accepted medical standards and practice. Other names used for such a form are POST (Physician Orders for Scope of Treatment), COLST (Clinician Orders for Life Sustaining Treatment), MOST (Medical Orders for Scope of Treatment), and similar variations.
However, just like DNR orders, POLSTs require the full participation of the patient or the patient’s surrogate, as mentioned earlier. In January 2020, the Department of Veterans Affairs Office of Inspector General (VAOIG) published an inspection report critical of the way many DNR orders are obtained. Some clinicians behave in imperious ways and issue DNR orders without appropriate consultation with patients or their surrogates, or they impose their own ethical values on the discussion, rather than serve as a conduit for straight-forward evidence-based, information about the patient’s prognosis and treatment options. When the clinician disagrees with a patient’s decision and refuses to follow it, a referral to another provider is essential and required by widely-accepted standards of medical care and ethics. The same concerns identified by the VAOIG about DNRs exist with POLSTs.
Whenever a clinician, unwilling to follow a patient’s or surrogate’s decisions about medical care, fails to make appropriate referrals, it is the patient’s or surrogate’s responsibility to insist on a referral to a clinician willing to implement the patient’s decisions.
For more information about POLSTs, see National POLST.
Summary
Patients complete advance directives without a physician’s approval, though they may seek a physician’s advice in doing so. Only a physician can issue a DNR order or a POLST, in consultation with the patient or surrogate. So long as the preferences and directives of patients are an integral part of the process, POLSTs appear to be a useful addition to late-stage medical care decision making.
