Legislation to implement Practitioner Orders for Life-Sustaining Treatment (POLST)

Introduction
Legislation to implement Practitioner Orders for Life-Sustaining Treatment (POLST) was signed by Gov. Chris Christie in December 2011. POLST is intended to promote an adult’s right to self-deter- mination and autonomy with respect to goals of care, treatment preferences and choices, to clarify
treatment choices and goals and to reduce repetitive actions and inappropriate hospitalizations/transfers.
Completing a POLST form begins with a conversation between a physician/advance practice nurse and the individual, typically one with advanced, progressive chronic disease in the last months/years of life, to determine goals of care and treatment preferences in key areas of life-sustaining treatment, including resuscitation, artificial nutrition and hydration and hospitalization. These conversations can occur in any healthcare setting. The conversation should be guided by a healthcare professional with sufficient exper- tise to discuss the medical facts of the individual’s situation and the likely risks and benefits of various treat- ments. The N.J. POLST form is structured to help guide conversations that might otherwise be difficult or non-productive. It allows for a review and documentation of some key decisions in a standardized format, and encourages frequent review as the individual’s health situation evolves.
Preferences for care and treatment may have been documented in previous advance directives, living wills, or medical powers of attorney (POA), but none of those are a provider’s medical order. Completion of a POLST does not revoke those documents and those documents should be referenced when completing the POLST form. The POLST must be signed by the MD/APN and voluntarily by the individual with de- cision-making capacity or by the individual’s authorized agent in accordance with the individual’s known preferences or in the best interest of the individual. Completion of a POLST does not revoke documents such as advance directives, living wills, or medical powers of attorney; those documents compliment the POLST and all of those remain in effect documenting the individual’s preferences. The POLST overrules prior instructions only when they conflict directly. Completion of a POLST, however, does invalidate all previous POLST documents.
The N.J. form provides a section where the individual can indicate the only person(s) who can change a POLST form in the event the individual is incapacitated. POLST travels with the individual and must be honored in all settings, ie. hospital, clinic, ambulatory surgery center, long term care, rehabilitation facilities, long term acute care hospitals, assisted living, hospice, during transit by pre-hospital providers or home. The portability of the form allows seamless documentation of treatment goals and preferences and closes gaps as individuals transfer across healthcare settings. The form is a brightly colored green for easy recognition, but photocopies, faxes and electronic scans also are valid.

The POLST Form
The POLST form serves to translate the individual’s treat- ment goals into a set of portable medical orders that must be honored in all settings. In a healthcare facility, the
form should be the first document in the clinical record and should be recognized as a set of medical orders implemented in the same manner as all other medical orders. In a non-institutional setting, the form should be placed in a location that is easily accessible and likely to be seen by first responders and EMS personnel.
In the absence of a POLST form or another state-specific med-
ical orders form, individuals will receive the routine emergency
medical care, including advanced cardiac life support, CPR, invasive airway management and defibril- lation. Therefore it is essential that, if an individual does not wish to undergo these interventions, the POLST form be readily available. The form is a brightly colored green for visibility and recognizability and should accompany the individual whenever he/she is transferred or discharged to a facility or care setting.
It should be noted that the use of the POLST form is entirely voluntary, is not required by law, and is ultimately the individual’s decision to complete or not. The form is most appropriate for individuals with life-limiting or terminal illnesses. To determine whether a POLST form should be encouraged, clinicians should ask themselves whether they would be surprised if the person died in the next three to five years because of a serious life-limiting illness. If they would not be surprised, then a POLST form is probably appropriate. A POLST form is designed to express the individual’s preferences for levels of treatment and other artificial life support and can indicate either full treatment including resuscitation attempts or can be used to limit those interventions that are not desired by the individual. POLST forms, therefore, are most useful for people who:

•  Are seriously ill with life-limiting advanced illness
  
•  Have advanced frailty with significant weakness and difficulty with daily personal activities
  
•  May lose the capacity to make their own healthcare decisions within the year
  
•  Hold strong preferences about their end-of- life care
  
•  Are chronically ill individuals who have fre- quent contact with the healthcare system
  

•  Individuals who reside in long term care fa- cilities.
  
•  Unlessitistheindividual’spreference,theuse of the POLST form to limit treatment is not appropriate for patients who are medically sta- ble or who have functionally disabling prob- lems but have many years of life expectancy.
  

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Emergency responders required to honor POLST
The New Jersey law regarding POLST requires that all healthcare providers, including pre-hospital providers such as first responders or EMS personnel, must follow the orders as delineated on the POLST form.
ADVANCE DIRECTIVES AND POLST WORK TOGETHER IN ADVANCE CARE PLANNING
The Advance Directive
Advance directives are legally recognized documents that are designed to reflect an individ- ual’s medical goals and treatment preferences in the event that he/she is unable to give consent in the future. These are recommended for all capable adults, regardless of health
status, and allow individuals in New Jersey to:

•  Designate a person (surrogate decision maker/proxy) and give that person the legal authority to make decisions on treatment issues for the individual if the individual is unable to make decisions for himself/herself on treatment issues
  
•  Provide those responsible for the care of the individual with a statement of the individual’s medical treatment preferences. This usually entails written directions that, in advance, outline what medical treatments the individual wishes to accept or refuse and the circumstances in which the individual wants those directions implemented.
  Key Differences between the Advance Directive and POLST
  

Advance Directive	POLST
Not a medical order; requires evaluation by a physician of the individual’s diagnosis/prognosis and preferences with regard to present condition. Usually treatments cannot be lim- ited in an emergency situation with only an Advance Directive. Therefore, unwanted treatments and interventions may be ap- plied.	Is a medical order that guides the care provided by all healthcare providers.
Helps people communicate treatment preferences in advance of a serious illness and designates a proxy to make decisions should the individual lose capacity to do so.	Reflects the individual’s goals of care and wishes around care near/at the end of life and trans- forms them into actionable orders that must be followed by all healthcare professionals.
Recommended for all adults with decision-making capacity.	Recommended for individuals with advanced illness, frailty or strong preferences about medical interventions in their current state of health.

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How the Advance Directive and POLST can Work Together
As long as individuals retain decision-making capacity, they can modify or void their POLST at any time to reflect any changing wishes regarding their goals of care or treatment preferences as the circumstances surrounding their illness changes. The orders on the form are still valid when
the individual loses capacity and unless the individual has designated a surrogate on the front of the form, no one can modify the POLST form other than the individual.
How the Out of Hospital DNR Form Works with POLST
Once a POLST document has been executed by the individual and his/her physician or advance practice nurse, the Out of Hospital (OOH) DNR Form can be destroyed. POLST replaces the OOH DNR since all healthcare providers, including pre-hospital providers like EMS personnel and first responders, must follow the orders on the POLST form.

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HOW TO USE THE POLST FORM TO RECORD AN INDIVIDUAL’S PREFERENCES
The Discussion with the Individual
Completing the POLST form should follow a thorough discussion with the individual/surrogate based on the individual’s medical treatment preferences at the time of discussion. The organiza- tion of the form is such that it may serve as a template or script for the discussion as it may occur
at the bedside, beginning with the person’s goals and ending with a recommendation regarding resuscita- tion. Attempts should be made to frame the Goals of Care question within the context of the individual’s prognosis, and make medical recommendations to help them achieve their treatment goal, whether they be full therapeutic efforts to sustain life or more palliation for comfort. The physician or advance practice nurse should avoid beginning the Goals of Care conversation with CPR status and should attempt to offer this as a recommendation based on realistic goals and the likelihood of surviving CPR.
This discussion must include the individual if he/she has capacity. For minors, the discussion must be with the parent(s) or legal guardian. Others who may be included, with the individual’s consent, are:
Court-appointed guardian or other legally appointed decision maker Spouse, civil union partner or children
Others
NOTE: When filling out a POLST form, always specify who the “other” is and the relationship to the individual.
Determining a Surrogate
If the individual has decision-making capacity, he or she may appoint a healthcare representative/sur- rogate decision maker on the POLST form to make decisions in the event the individual later loses deci- sion-making capacity. If there is conflict between the individual named on this POLST form and another document, such as a previously executed POLST form or advance directive, confirm with the individual who the designated surrogate decision maker should be. If the individual does not have decision-making capacity upon the initial execution of a POLST form, the healthcare providers must rely on a surrogate decision maker, such as a healthcare representative named in an advance directive or other surrogate de- cision maker authorized by law, to complete the POLST form.

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THE POLST FORM
Signatures
APOLST form must be signed by a physician or advance practice nurse in order to be valid. The healthcare professional’s information should be filled out on the form and must also bear the professional’s signature. By signing the form, the healthcare professional assumes full respon-
sibility for the medical orders that are documented similar to any other medical order in the individual’s chart and acknowledges that these orders reflect the individual’s or the designated decision maker’s current wishes for treatment.
Also note that sometimes an individual is evaluated and has a POLST form completed by a physician or APN not on the medical staff of that particular facility; in this case, healthcare professionals are still required to honor the orders of the POLST form.
It is legally mandated for the POLST form to be voluntarily signed by the individual with decision-mak- ing capacity, or by the individual’s representative in accordance with the individual’s known preferences or in the best interest of the individual in order for the form to be valid in New Jersey. If they cannot sign, it should be so noted on the form.
Storing the POLST Form
The POLST form provides documentation of the individual’s preferences and provides medical orders accordingly. In healthcare facilities, POLST should be readily accessible in clinical records and in home settings, it should be in a highly visible location that EMS personnel and first responders are likely to see, such as attached to the kitchen refrigerator, by the telephone, by the individual’s bed or on the inside of the front door. Individuals should keep the original copy of the POLST form with them at all times.
Transferring an Individual with a POLST Form
For individuals in healthcare facilities, the original form should accompany them when transferred from one facility to another, as a copy of the form should be kept in the medical record. HIPAA enables the disclosure and transfer of POLST orders to other healthcare professionals, as necessary. A copy of the POLST form should be given to EMS personnel and ambulance staff before transferring the individual. It is important that they can access and review the form itself, therefore it should not be included in transfer documents in a sealed envelope.

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Dealing with Disputes Regarding a POLST Form
Disputes regarding existing treatment orders in a POLST form typically are based on who has deci- sion-making authority or what those decisions ought to be. This may occur when a family member requests treatment for the patient that conflicts with what is indicated on the POLST forms. In spite of this, the POLST form is legally binding for all providers and cannot be changed by anyone unless the individual has so designated on the front of the form.
Revising/Voiding a POLST Form
The healthcare professional responsible for the individual’s care should review the form with the individual and update the POLST orders as the individual’s medical conditions, goals and treat- ment preferences change.
POLST should be reviewed and updated periodically if the individual:
Is transferred to a different care setting
Experiences a significant change in health status Changes his or her treatment preferences
Changes his or her primary care provider.
Sometimes, however, the need to follow the POLST orders occurs before a revision and update of the POLST form is possible. In this scenario, POLST orders should still be followed by EMS personnel or other providers until a review is completed by the appropriate healthcare professional.
An individual with capacity or the individual’s representative who is designated by the individual or otherwise authorized under law to make healthcare decisions on behalf of the individual who lacks deci- sion-making capacity, may void the POLST form at any time and request different treatment. This can be done by:

•  Drawing a line through sections A through F and writing “VOID” in large letters on a paper form
  
•  If the POLST form is maintained via an electronic medical record kept by the facility, it must be
  voided in accordance with the institution’s procedures.
  

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Section-by-Section Review of POLST Form
The first section on side one of the POLST form is: A – Goals of Care
Side one of the POLST form also lists three different medical treatment sections:
B – Medical Interventions
C – Artificially Administered Fluids and Nutrition
D- Cardiopulmonary Resuscitation (CPR) and Airway Management
This page also contains two sections related to documentation and signatures:
E – Identification and authorization of a surrogate decision maker in the event that the individual loses decision-making capacity, and who is the only person who is able to modify or revoke the N.J. POLST orders in a consultation with the patient’s treatment physician or APN
F – Signature of the practitioner (MD/DO/APN) and of the patient or surrogate
Any of these sections, which constitute medical orders, that is not completed indicates that full treat- ment should be provided for that type of treatment until clarification is obtained.

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A – Goals of Care
While this section does not constitute a medical order, it prompts medical providers to have meaningful discus- sions with the individual around his/her future – using
questions like “what are your goals for the next month or year?” or
“what is meaningful in your life and how do you want to live it in the
months/years you have left?” Other questions might be “what is your
understanding now of where you are with your illness?” “how much
information about what may lie ahead with your illness do you want
to know” and “how much does your family know about your priori-
ties and wishes?” It is important to share information regarding the
prognosis in order to allow the individual to set realistic goals for care
to guide the completion of the remainder of the POLST form. Among these considerations are longevity and remission, quality of life, family events and performing daily activities.
B – Medical Interventions
GENERAL INSTRUCTIONS REGARDING LEVEL OF MEDICAL INTERVENTION
These orders apply to an individual who has is breathing and/or has a pulse.

•  Choose Full Treatment if all life-sustaining treatments are desired including use of intubation, ad- vanced airway intervention, mechanical ventilation, cardioversion, transfer to hospital and use of intensive care as indicated with no limitation of treatment.
  
•  Choose Limited Treatment when the individual prefers to be hospitalized for medical treatment (such as antibiotics and IV fluids as indicated) if needed, but wishes to avoid invasive mechanical ventilation and ICU care. Some individuals may only want to be hospitalized if their comfort needs cannot be met in their current location. Either of these two options can be indicated in this section.
  
•  ChooseSymptomTreatmentonlywhentheindividual’sgoalsaretomaximizecomfortandavoidhospi- talizations unless it is necessary to ensure that their comfort needs are met. The treatment plan is to re- lieve pain and suffering and maximize comfort by using any medication by any route, positioning, wound care or other measure such as oxygen, suctioning and manual treatment of any airway obstruction. Note that medication such as antibiotics may only be used to promote comfort. Individuals should only be transferred to a higher level of care if symptom management cannot be provided in the current setting.
  
•  Additional Orders to clarify the individual’s preferences can be written: e.g. “ICU treatment for sepsis but no intubation/mechanical ventilation for respiratory failure.”
  
•  Healthcare professionals should first administer the level of medical interventions ordered on the POLST form and then contact the physician/advanced practice nurse for further direction.
  

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C – Artificially Administered Fluids and Nutrition
These orders must account for the institution’s policies and the individual’s wishes regarding the use of ar- tificially administered nutrition and hydration for an individual who cannot orally intake food or fluids. Oral fluids and food must always be offered to the individual if medically feasible and desired.
D – Cardiopulmonary Resuscitation (CPR) and Airway Management
CARDIOPULMONARY RESUSCITATION
These orders apply only when the individual has no pulse and/or is not breathing. This section does not apply to any other medical circumstances. For example, this section does not apply to an individual in respiratory distress because he/she is still breathing. Similarly, this section does not apply to an individual who has an irregular pulse and low blood pressure because he/she has a pulse. For these situations, the first responder or healthcare provider should refer to section B and follow the indicated orders.
If the individual wants cardiopulmonary resuscitation (CPR) and CPR is ordered, then the “Attempt Resuscitation/CPR” box is checked. Full CPR measures should be carried out and 911 should be called. If the individual has indicated that he/she does not want CPR in the event of no pulse and/or not breathing, then the “Do Not Attempt Resuscitation/DNAR, Allow Natural Death” box is checked. CPR should not be performed and procedures for pronouncement of death should subsequently be followed.
Airway Management
These orders apply when the individual is in respiratory distress and has a pulse. In this scenario, an individual may wish to either be intubated, in which case artificial ventilation will be used as needed, or to not be intubated, in which case oxygen, manual treatment to relieve airway obstructions and medication for comfort will be used instead.
Note: some individuals with advanced illness might want all measures including intensive care treat- ment and temporary life support such as mechanical ventilation, but would not want to be resuscitated if these attempts fail and their heart stops. Thus, an individual can request DNAR in Section D and re- quest Full Treatment in Section B, selecting “Intubate” or “Do Not Intubate” in the Airway Management Section, depending on personal preference and goals of care.
E – Surrogate Designation
This section can only be completed by the covered individual and his/her physician or APN when the individual has decision-making capacity
When completing the form, the individual can indicate whether or not he/she wants to authorize a surrogate who can modify/revoke the POLST document. Only if so authorized in this section of the form, may changes be made to the POLST form by anyone other than the individual.

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F – Signatures
Upon completion of the orders, the physician (MD/DO) or APN must sign and date the POLST form in acknowledgement that the orders on the form are consistent with the individual/surro- gate preferences. POLST orders also should be signed by the individual/surrogate and it should
be indicated on the signature line if the individual/surrogate is unable to sign, declined to sign or gave verbal consent. Without an MD/DO/APN signature, POLST orders are not valid.
The boxes to be checked regarding organ and tissue donation are meant to ascertain if the individual has documented a decision on organ donation. The individual must understand that documenting an anatomical gift on the POLST form only records an existing gift. Unlike an advance directive or driver’s license registry, the POLST form cannot be used to make, or refuse to make, an anatomical gift, and it will not change the terms of an existing anatomical gift. If a gift has been made, the POLST form will not impede that gift. If the patient has not made an anatomical gift, his/her survivors will be asked to donate, if appropriate, regardless of what is checked on the POLST form.
The Reverse Side of the POLST Form
CONTACT INFORMATION
HIPAA permits the disclosure of the POLST form to other healthcare providers as necessary.
DIRECTIONS FOR HEALTHCARE PROFESSIONALS
This section addresses common questions that may arise when using the POLST form.
Key points include:

•  The voluntary nature of the POLST for individuals with advanced illness and/or frailty
  
•  The POLST form should reflect the individual’s wishes now, in his/her current state of health. If the individual’s wishes change in the future as his/her health changes, and if the individual maintains capacity, he/she can update the POLST form
  
•  Verbal orders, photocopies, faxes and electronic forms are valid and legal, so long as verbal orders are accompanied with a follow-up signature by the physician/APN
  
•  Information regarding reviewing, modifying and voiding the POLST
  
•  Overall guiding goals and questions regarding the completion of each section.
  

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Additional Resources
For Patients and Families
More information about N.J. POLST can be found at: www.goalsofcare.org.
For more information on National POLST Paradigm Programs and the National POLST Paradigm Task Force, visit: www.ohsu.edu/polst.
NJ Organ Procurement Organizations
The Sharing Network, 800-742-7365, www.njsharingnetwork.org Gift of Life, 215- 557-8090, www.donors1.org

source http://www.njha.com/media/85298/PolstGuide.pdf 

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