PROBLEMS WITH
PHYSICIAN ORDERS FOR
LIFE-SUSTAINING TREATMENT (POLST)
WHICH CAN BE SOLVED BY ELMO
(End-of-Life Medical Orders)
SYNOPSIS:
POLST stands for Physician Orders for
Life-Sustaining Treatment.
But sometimes it was not
created by a physician
and usually it merely rejects
life-sustaining medical treatments.
POLST attempts to summarize the patient's end-of-life wishes,
without making certain that the patient knows what is being
rejected.
All of the problems that have arisen with POLST
can be overcome or prevented by a new kind of medical order:
End-of-Life Medical Orders (ELMO).
OUTLINE:
1.
FREQUENTLY THE WRONG PERSON
HELPS THE
PATIENT FILL OUT THE POLST.
2.
POLST CONTAINS NO BACKGROUND MEDICAL INFORMATION.
3.
POLST HAS AN UNCLEAR RELATIONSHIP WITH
ANY ADVANCE
DIRECTIVE FOR MEDICAL
CARE.
4.
POLST HAS A VERY LIMITED RANGE OF MEDICAL OPTIONS.
5.
POLST DOES NOT HAVE ENOUGH SPACE TO EXPLAIN CHOICES.
6.
SOMETIMES 'ADVISORY' OR 'DRAFT' POLSTS ARE CREATED.
7.
POLST WAS POORLY NAMED.
RESULTS:
Future
patients who once thought that POLST
was a satisfactory end-of-life medical plan
will see the need for more medical information
and more explanation of the choices.
PROBLEMS
WITH POLST
by
James Leonard Park
1. FREQUENTLY THE WRONG PERSON
HELPS THE
PATIENT FILL OUT THE POLST.
Even tho a doctor will ultimately sign the POLST along with
the patient,
sometimes the doctor did not
have any meaningful conversation
with the patient about this two-page medical order.
POLST too easily becomes yet another form to be
filled out
in the doctor's office, the clinic, or the hospital admissions
department.
The health-care worker who explains each choice might be
a nurse, a social worker, a care assistant, an admissions coordinator,
or even a business manager.
Perhaps the doctor has a pile of POLSTs in his
in-box.
He will sign them when he has some time.
But will he remember which patient is which?
Does he pay attention to the choices made?
Was there any meaningful discussion with this patient
about end-of-life medical care?
The solution is for the End-of-Life Medical Orders
(ELMO)
to arise from detailed
discussions
between the patient and the licensed physician
who is most likely to be present at the end.
The dates and the duration of these planning
sessions
should become part of the ELMO document itself.
This patient and this physician are agreeing in writing
about how terminal medical care will be provided.
2. POLST CONTAINS NO
BACKGROUND MEDICAL INFORMATION.
POLST merely shows that some time in the past
this patient created a short statement
about what forms of medical care will be provided
and what life-sustaining treatments will be rejected.
Without any explanation of the medical condition of the patient,
no tubes, no hospitalization, no CPR does not make any sense.
If the patient and doctor have chosen comfort-care only,
what are the reasons
for making this decision about the end-of-life?
End-of-Life Medical Orders (ELMO) will fill this
void
with an explanation of
the patient's medical condition and prognosis.
And given the stated medical problems,
the planned end-of-life medical care will make more sense.
3. POLST HAS AN UNCLEAR
RELATIONSHIP WITH
ANY ADVANCE
DIRECTIVE FOR MEDICAL
CARE.
Under some state laws, the POLST replaces the Advance
Directive.
Sometimes the most recent
document prevails.
But the original intent was for the medical order to put into practical
action
the wishes earlier expressed in an Advance Directive for Medical Care.
Advance
Directives
for Medical Care should be created years before need.
While the patient is still in good health and thinking clearly,
he or she should create a comprehensive document
exploring all dimensions of wanted medical treatments
—and
any limitations that should be placed on future medical care.
POLST usually has weaker witness-requirements than
Advance
Directives.
Witnesses are supposed to assure that the author of the Advance
Directive
was well-informed and mentally-competent when making those plans.
But POLSTs can be quickly completed, without much thought or
consultation.
Sometimes surrogates are the ones who fill out
POLSTs.
And there are few safeguards to make certain
that surrogates are not simply inserting their own wishes.
The End-of-Life Medical Orders will clearly refer to
any Advance Directive
and seek to put into action the wishes and preferences
expressed earlier by the patient in the Advance Directive.
For example, the patient might have said in the Advance Directive
that he or she does not want Cardio-Pulmonary Resuscitation (CPR).
If the terminal-care physician agrees the resuscitation
would be
useless,
then this preference can be put into an actionable medical order:
If this patient's heart and/or lungs stop working,
no attempts will be made to
re-start them.
The "crash-cart" will not
be called.
The patient will be allowed to die.
Each ELMO and AD should refer to each other.
The Advance Directive should be updated
to take into account the most recent medical developments.
When End-of-Life Medical Orders are written
to put the medical plans for this patient into action,
the existence of the medical orders for the last few months
should be referred to in the Advance Directive:
"My End-of-Life Medical Orders
created in consultation with my (named) terminal-care
physician
is filed at (location) on the Internet."
4. POLST HAS A VERY LIMITED
RANGE OF MEDICAL OPTIONS.
Usually there are only three general choices:
1. Full medical treatment to cure any disease or injury.
2. Intermediate care, perhaps tried for a brief period.
3. Comfort-care only, reducing suffering while the patient dies.
Sometimes specific medical treatments are mentioned:
CPR—Cardio-Pulmonary
Resuscitation
Antibiotics—to
cure any infections
Hospitalization—should
this patient be taken to a hospital?
Intubation—should
any tubes be used?
Because the POLST form was created for all
possible
patients,
it necessarily asks for standardized responses only
—boxes
on a form, checked or unchecked.
Sometimes hand-outs accompany the POLST form,
which are supposed to explain the options.
But often the hand-out tells only one side of the story,
for example how CPR can lead to broken ribs and other trauma.
Because the options in POLST are few
and standardized,
there is seldom much impetus to discuss the specifics
of this patient's end-of-life medical care.
There is no exploration of the details of terminal care
or the life-shaping implications of any options selected.
Since check-boxes leave no
room for explanation,
even if the physician and patient want conditions and
exceptions,
there is no easy way to customize the POLST.
End-of-Life Medical Orders are created specifically
for this one patient.
Given the most likely cause of death,
the doctor and the patient choose the best forms of medical care.
Instead of sweeping rejection of all medical
treatments,
the ELMO can specify which
kinds of life-saving efforts will be applied
and which forms of
resuscitation will be omitted as useless.
5. POLST DOES NOT HAVE ENOUGH SPACE
TO EXPLAIN
CHOICES.
Because of the prior decision to limit this medical
form to just two pages,
there is not enough space to explain any of the medical choices.
What if there should be exceptions to some choice
under specific circumstances?
For example, would this patient want surgery for pain-control,
even if the surgery would not extend the life of the patient?
Since ELMOs are computer files from the beginning,
any section can be expanded to explain specific medical facts
or the choices of this particular patient.
One of the ironies of limiting POLSTs to just two
pages
is that these forms are often scanned
for electronic storage and sharing.
Thus, the hand-written answers on the lines of the form
are reproduced exactly as they appear on the original
in the computer memory system.
Much more data-space
is needed to store pictures
of these two pages
than would be required for an electronic text with
words only.
If it is going to be stored and shared like any
other computer files,
why not put the plans into easily-readable explanations in English?
6. SOMETIMES 'ADVISORY' OR 'DRAFT' POLSTS ARE CREATED.
These are preliminary plans,
created before the
patient is definitely in the last 12 months of life.
The specific physician who will provide terminal care
might not yet have been selected and agreed to provide that service.
Thus, such documents are more like Advance
Directives for Medical Care.
When specific terminal conditions emerge,
then a definite end-of-life plan will be created,
perhaps beginning with the advisory POLST and/or the Advance Directive.
Likewise, whenever the terminal-care doctor changes,
a new agreement between that new physician and the patient
should be created.
Because of its electronic form,
ELMOs can be revised, updated, & expanded at any time.
Any revised ELMO can begin with the previous version,
instead of starting over with a blank POLST-form each time.
7. POLST WAS POORLY NAMED.
POLST stands for Physician Orders for
Life-Sustaining Treatment.
MOLST stands for Medical Orders for Life-Sustaining Treatment.
COLST stands for Clinical Orders for Life-Sustaining Treatment.
These three are all basically the same forms
—with different names in different states.
But the content is usually much more comprehensive
than just what life-supports
to apply or abandon.
End-of-Life Medical Orders (ELMO) includes
all relevant background medical information,
the most likely causes of death,
the preferred methods of managing dying,
the preferred place for dying,
and specific plans for end-of-life medical care.
AUTHOR:
James Leonard Park is an advocate for
consumer-rights in health-care.
He does have a comprehensive Advance
Directive
for Medical Care.
But since he expects to live several more years,
he has not yet selected a terminal-care physician
and has not helped to create a Do-Not-Resuscitate Order,
a POLST, or an ELMO for himself.
He has written a book about Advance Directives:
Your
Last Year:
Creating
Your Own
Advance Directive for Medical Care.
His longest book is How
to Die:
Safeguards for Life-Ending Decisions.
The
above critique of POLST is included as Chapter 44.
Much more about him will be discovered on his
personal website
---the last link below.
Created
May 22, 2015; Revised 5-23-2015; 6-4-2015; 6-8-2015; 6-10-2015;
10-7-2015; 11-30-2015;
5-31-2016; 6-13-2016; 12-21-2016; 10-4-2017; 9-28-2018; 5-2-2019;
5-14-2020;
Did this essay change your thinking
in any way?
Did you think before you started reading
that POLST was the best thing since Do-Not-Resuscitate orders?
Have you encountered any of the problems mentioned?
Do you think that ELMO might be a better way
to document end-of-life terminal-care plans?
If you are involved in some part of the health-care
system,
will you share this critique with others who might be interested?
Here is the URL:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/POLST.html