POLST Skills Development – Sharmon Figenshaw, ARNP, RN; and Bruce Smith, MD Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College

1. Physician’s Orders for Life-Sustaining Treatment
Sharmon Figenshaw, ARNP, Bruce Smith, MD
Washington POLST Task Force Co-Chairs

2. POLST Update for Professionals

3. POLST Update for Professionals
What is POLST?
 “Portable” medical orders for treatment decisions,
including end-of-life care; conforms to medical standards
of care.
 Defines patient preference for health care options based
on current physical/medical condition.
 POLST can translate an advance directive into
physician’s orders or reflect change in preferences
based on change in medical condition.

4. POLST Update for Professionals
What is POLST?
 Patient & provider shared decision-making model: Brings together
patient goals/values and practitioner-guided consideration of current
medical condition.
 Translates patient wishes into orders that can be followed by EMS
(and hopefully other bedside providers).
 Options include range of care from full code/full measures to
DNR/comfort.
 Power and portability
REMEMBER: Conversations for goals of care come first!

5. POLST Update for Professionals
Philosophy of POLST
 Individuals have the right to make their own health care
decisions. These rights include:
 Making decisions about accepting or refusing life-sustaining
treatment.
 Having their decisions honored by health care providers.
 Comfort care while having wishes honored.
 POLST allows people to “opt out” of the default “full
code” of standard emergency/medical care.

6. POLST Update for Professionals
POLST: Who Should Have One?
 Who should have POLST form:
 Persons with advanced or chronic illness, or frailty.
 Condition for which resuscitation is inappropriate including when
survival is unlikely.
 Anyone who “you wouldn’t be surprised” if they were to die
within the next year.
 Good clinical documentation
 Especially when surrogates are decision makers.

7. POLST Update for Professionals
POLST: Who Could Have One?
 Anyone choosing:
 To limit medical treatments
 Do Not Resuscitate/No Code/Allow Natural Death
 Advanced age >80 years old (without mental instability)
This covers our healthy seniors who want to make sure that they do not
receive unwanted CPR or burdensome hospitalizations.*
*There is some debate about this in religious circles.
It is important to remember: POLST is always voluntary!

8. How an Advance Directive and POLST Form Work Together

9. POLST Update for Professionals
Establish Goals of Care
 Shared decision-making based on the patient’s values
and goals in light of their current medical condition:
 “What do you understand about your condition?”
 Informed consent: Patients need information about risks
and benefits of life-saving measures!
 “What are you hoping for? What might you be afraid of?”
 Initiate in the hospital by the time of discharge if not
already done by primary care provider.
 “How would you like to live your life?”

10. How POLST
Works

11. The POLST Form (Front)
Medical Condition/Patient Goals
 A simple description of medical condition
 A direct statement of the patient/family’s goals in their own
words is one of the most important pieces of information we can
gather.
 This may guide care decisions when nothing else can.
Agency Info/Sticker
 Write in, or place sticker here for an agency.

12. The POLST Form (Front)
Part A: Code Status
 Instructions regarding Cardiopulmonary Resuscitation
(CPR): Includes EMS
Patient has no pulse and is not breathing
 CPR/Resuscitate
 Do Not Attempt Resuscitation (DNAR) / Allow Natural
Death (AND)
 Comfort measures will always be provided

13. The POLST Form (Front)
Part B: Medical Interventions
Patient/resident has pulse and/respirations
 Comfort Measures Only:
 Medication by any route, positioning, wound care.
 Other measures to relieve pain and suffering.
 Use oxygen, oral suction and manual treatment of airway
obstruction as needed for comfort.
 Patient prefers no transfer: EMS contact medical control to
determine if transport indicated.

14. The POLST Form (Front)
Part B: Medical Interventions
Patient/resident has pulse and/respirations
 Limited Additional Interventions:
 Includes care listed above in comfort care.
 Medical treatment, IV fluids and cardiac monitor as indicated.
Do not use intubation or mechanical ventilation.
 Transfer if indicated, avoid ICU if possible.

15. The POLST Form (Front)
Part B: Medical Interventions
Patient/resident has pulse and/respirations
 Full Treatment and Interventions:
 All care in both sections above plus intubation and
cardioversion.
 Transfer to hospital if indicated. Includes intensive care.
 Additional Orders: (e.g. dialysis, etc.)
 Use this section to state specific therapies, like dialysis and
blood transfusions and the goals or time limits for these.

16. The POLST Form (Front)
Signatures
 Statement of Intent:
 The signatures below verify that these orders are consistent with
the patient’s medical condition, known preferences and best
known information. If signed by a surrogate, the patient must be
decisionally incapacitated and the person signing is the legal
surrogate.
 Indicate who was involved in decision-making:
 Patient
 Parent of minor
 Guardian with Health Care Authority
 Spouse (or Domestic Partner. Indicate this)
 Health Care Agent (DPOAHC)

17. The POLST Form (Front)
Signatures
 Patient signature always preferred.
 If patient present but surrogate signing, note presence and
agreement of patient.
 Surrogates for signing (Washington state):
 Guardian
 DPOA
 Spouse/Registered domestic partner
 Adult children
 Parent
 Adult sibling
 Beyond that, there is no regulatory guidance. Consult ethics. Use
team-decision making model with any family available.

18. The POLST Form (Front)
Signatures
 Physician (MD, DO) or Advanced Care Practitioner
(ARNP or PA-C) must sign.
 Verbal orders are acceptable with follow-up signature by
physician, ARNP or PA in accordance with existing
policies.
 Signatures attest to the informed consent process having
occurred.
 Different health care settings designate/train different
personnel for this purpose.

19. The POLST Form (Back)
Part D
 Additional Patient Preferences (Optional)
 This includes antibiotics and nutrition therapy options.
 Formerly Parts C & D on front of form.
 Meant to guide therapies in non-emergent situations.
 Patient and provider signatures testify that conversation has
taken place.

20. The POLST Form (Back)
Part D: Antibiotic Therapy
 Antibiotics for infection: whatever the choice, notify
physician of new infection
 No antibiotics: use other measures to relieve symptoms.
 Determine use or limitation of antibiotics when infection occurs,
with comfort as goal.
 Use antibiotics with the goal of prolonging life.

21. The POLST Form (Back)
Part D: Medically Assisted Nutrition
 Artificially Administered Nutrition by parenteral or enteral
route
 No artificial nutrition by tube.
 Trial period of artificial nutrition by tube. (Goal: Write in how
long, till what event or goal is reached.)
 Long-term artificial nutrition by tube.
 Always offer food and liquids by mouth if feasible.
 Additional orders:
 Name specific goals of patient.

22. The POLST Form (Back)
Directions for Health Care Professionals
 Completing POLST
 Must be completed by health care professional.
 Members of the health care team, RN, MSW, with proper training are well-
positioned to have the appropriate conversations.
 Should reflect the person’s current preferences and medical
indications. Encourage completion of an advance directive.
Advance directive should indicate congruent choices.
 POLST must be signed by a physician (MD or DO)/ARNP/PA-C
to be valid. Verbal orders are acceptable with follow-up
signature per facility policy (see sample policies available at
awphd.org or wsha.org).

23. The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST
 Any incomplete section of POLST implies full treatment for that
section.
 This POLST is effective across all settings including hospitals
until replaced by new physician’s orders.
 The health care professional should inquire about other advance
directives. In the event of a conflict, the most recently completed
POLST form takes precedence.

24. The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST: SECTION A
 Patient has no pulse/no respirations
 No defibrillator (internal or external) should be used on a person
who has chosen “Do Not Attempt Resuscitation.”

25. The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST: SECTION B
 When comfort cannot be achieved in the current setting, the
person, including someone with “Comfort Measures Only,”
should be transferred to a setting able to provide comfort (e.g.,
treatment of a hip fracture).
 An IV medication to enhance comfort may be appropriate for a
person who has chosen “Comfort Measures Only.”
 Treatment of dehydration with IV fluids may prolong life. A
person who desires IV fluids should indicate “Limited Additional
Interventions” (or “Full Treatment” if more aggressive care
desired).

26. The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST: SECTION D
 Oral food and fluids must be offered if feasible.

27. The POLST Form (Back)
Directions for Health Care Professionals
 Reviewing POLST: Review when:
1) The person is transferred from one care setting or care level to
another, or
2) There is a substantial change in the person’s health status, or
3) The person’s treatment preferences change.
 A person with capacity, or the surrogate of a person without
capacity, can void the form and request alternative treatment.
 FORM CAN BE VOIDED; changes require new POLST. (Desire for
CPR and full treatment do not require POLST.)

28. POLST
Resources

29. POLST Resources
Washington State Medical Association
 Provides POLST forms and information.
 Order at www.wsma.org/polst or call (206) 441-9762.
 For general POLST information contact: Graham
Short, WSMA associate director of communications,
(206) 329-6851, gfs@wsma.org.
Washington POLST Task Force Co-Chairs:
 Bruce Smith, MD: bruce.smith@regence.com.
 Sharmon Figenshaw, ARNP: shar@dslnorthwest.net.