Susan Tolle, MD is a practicing internist\and Professor of Medicine in the Division of General Internal Medicine and Geriatrics at Oregon Health and Science University and is Director of the Center for Ethics in Health Care at OHSU. Dr. Tolle partnered with other healthcare leaders to design and implement systems for improving end-of-life care and discussed a problem and a solution found in Oregon to help assure individual choices at end-of-life are respected. The following is her account.

Martha Johnson is an elderly woman with advanced dementia who lives in a skilled nursing facility. She previously completed an advance directive requesting "do not resuscitate" status and no intensive care. She has also completed paperwork appointing her daughter to make medical decisions. One Saturday night she is overcome with a fever, cough, and shortness of breath. Her facility is unable to reach her daughter and transfers Mrs. Johnson to the nearest hospital where she is admitted to the intensive care unit and placed on a ventilator. On Monday, Mrs. Johnson’s daughter learns what has happened and demands to know why the nursing home orders were ignored. Why did this happen?

Completing an advance directive or living will is often not sufficient to ensure that patient wishes to have or to limit care will be consistently respected. Advance directives are general statements of patient preferences but need to be carried out through specifications in medical orders when the time comes. Even medical orders have limited authority outside of the institutions in which they are written. For example, physician orders at the nursing home usually have no authority in the ambulance or at the hospital.

Mrs. Johnson needed a document with medical orders that were consistently followed at each step of her care, from the nursing home to the ambulance to the emergency room to the intensive care unit. This is what the Physician Orders for Life-Sustaining Treatment (POLST) form accomplishes. The POLST form is a standardized set of medical orders developed in Oregon and implemented in parts of 18 states. POLST orders are primarily intended for use by persons with advanced chronic illness who wish to turn some aspects of their advance directives or advance care plans into action at the present time.

Key elements of the POLST program are:

A protocol. Policies and procedures for asking about patient preferences, completing a physician order (POLST form), transferring it with the patient across healthcare systems, and implementing it at each step in the transfer process.

A form. This is a standardized order form, signed by a physician, detailing patient wishes to have or to limit specific medical interventions such as CPR and mechanical ventilation. The form is brightly colored and placed in an obvious location so that medical personnel can easily find it.•

Education for all parties involved—patients, families, healthcare professionals and health systems.

Revision of the materials at a statewide level to incorporate regional, cultural, legal, and other differences.

Ongoing research about the experiences of different states and regions currently utilizing the POLST program.

Dissemination of data and resources to other states and regions wishing to adopt the POLST paradigm. There is strong evidence that this approach really works. Persons in Oregon using the POLST virtually always have their decisions honored, even during transfer to a hospital at the time of a serious complication. Persons living with serious chronic illness are advised to have a POLST with them at the time of any serious exacerbation.

Currently, it is recognized that system failures may result in patients’ choices for end-of-life care not being followed. As a solution, physicians and others here in Pennsylvania are encouraging implementation of the POLST paradigm as it provides a better means to identify and respect patients’ wishes than an advance directive. Awareness of the value of POLST as an instrument to guide medical treatment at the end-of-life is increasing here and a number of hospitals and long-term care facilities now using POLST in Pennsylvania.

In two facilities, the POLST form has been used for over seven years and the medical director comments, "Beyond the obvious advantage of each patient’s wishes being documented and followed, I have noticed a subtle change in the way we approach end-of-life issues. The patients, family, and staff have a better understanding of the treatment options and the consequences of these choices. Resuscitation, advanced treatment, short and long term feeding tubes and the option of future hospitalizations are specifically addressed. Families are made aware, sometimes for the first time, of what their loved ones feelings are on these critical issues, and it opens up an avenue for further discussion. When the resident ultimately passes away there is a high level of confidence that everything that should have been done was done, and this greatly aids in the grieving process. Since implementing the POLST form our percentage of residents who die in the hospital has been cut in half and satisfaction levels have increased. I strongly support the introduction of the POLST form state-wide in Pennsylvania." Achieving effective and wide spread implementation of the POLST requires education and communication.