Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

POLST and well-intentioned advance directives

Heather Alva
Physician
May 12, 2015
Share
Tweet
Share

Somewhere along the way I learned to believe that if a declaration is written down on physical paper and signed, it carries with it an almost magical certainty of follow-through: it can be framed, cited, stored in a safe, and, if need be, brandished in a court of law. This is an interesting idea in the realm of advance directives.

Well-intentioned advance directives

The goal of an advance directive is to protect patient autonomy. Patients can document the extent of medical care they would like to receive if circumstances render them unconscious or otherwise unable to express their wishes. Patients can designate surrogates, but to be clear, the idea of documenting ‘comfort measures only’ in an advance directive seems more hopeful than practical.

In a recent New York Times article, the author explains the fallibility of advance directives in an emergency setting. In practice, emergency medical responders have standing orders to resuscitate. This allows for the time to stabilize and assess a patient’s state of health by clinicians in a hospital setting before moving forward. Decisions that may impact the remainder of a patient’s life deserve to be made in a timely yet deliberate manner and with as much information as can be gathered from loved ones and hopefully then from an advance directive.

The POLST in a pinch

The POLST or physician orders for life-sustaining treatment is a state health initiative, pioneered by Oregon and West Virginia and now in the works for nearly forty of the fifty states, with some variation in name from state to state. The difference between an advance directive and the POLST is that the POLST is a physician’s order, signed by an MD, DO, nurse practitioner, or physician’s assistant. It is meant to travel with a patient across care facilities — hospitals, skilled nursing facilities, and hospice — and can be easily accessed by emergency medical services through an electronic state registry. A POLST order, but not an advance directive, can signal emergency services to not resuscitate a patient. The POLST is a wonderful example in its implementation of how interdisciplinary care can coordinate around a patient’s preference.

The Oregon POLST (PDF) is a one page, double-sided document, divided into three sections. A patient can decline CPR in the event that they are found not breathing and without a pulse, but can still request full treatment if they are found breathing or with a pulse. The distinction is an important one for many people, and one which is respected by this type of documentation.

A caveat, however, is that a POLST is only meant for patients believed to have a prognosis of six months or less. Both the patient (or patient surrogate) and provider must sign the document. The POLST is at its heart a tool to ensure that people who are close to death, who do not want to die in the hospital, are allowed a thoughtful yet timely discussion of their desires with the pre-existing knowledge of their prognosis.

Who is in charge?

Now that we have this tool, who is responsible for using it? In team-based medicine, we worry about bystander effect: if a patient has an oncologist, a primary care provider, and a palliative team, who should put it on their list of responsibilities to review the POLST with the patient? Common sense says that this should be a non-issue, that by nature none of the providers are “bystanders.” Yet even at my novice stage in medicine I’ve already heard a handful of stories about patients who are known to have extremely poor prognoses who were not explicitly told by their doctors, often because those doctors believed another provider had already had the conversation.

In a recent article in NEJM, three physicians write to address the different vantage points of this exact vignette. The authors submit reasons for why either the primary, the specialist, or the palliative team should bear the responsibility; the primary arguing for continuity as the best vehicle for this discussion, the specialist that they have sub-specialty knowledge of prognosis, in addition to having formed a relationship with the patient through a challenging life event, and the palliative proponent for their background in specialized communication training and a needs-driven care model. All three proposals seem to make sense.

It is clear that each provider has something unique to contribute to a conversation with a patient. One author adds that “with a high-functioning team, it may not matter whether [the patient] talks first to an oncologist, to a palliative care physician, or to her primary care physician. In the best case, all of [the patient’s] clinicians would contribute their particular expertise and personal touch at this pivotal time.”

I wonder instead of asking who is responsible, why aren’t we asking how we can form more effective interdisciplinary care teams for our patients?

Heather Alva is a medical student. This article originally appeared in The American Resident Project.

Prev

I encourage patients to fire me. Here's why.

May 12, 2015 Kevin 28
…
Next

Less is more in medicine: You get what you pay for

May 12, 2015 Kevin 14
…

ADVERTISEMENT

Tagged as: Palliative Care

Post navigation

< Previous Post
I encourage patients to fire me. Here's why.
Next Post >
Less is more in medicine: You get what you pay for

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Heather Alva

  • When applying for residency, should medical students be quantified?

    Heather Alva
  • a desk with keyboard and ipad with the kevinmd logo

    My first experience administering injections

    Heather Alva
  • a desk with keyboard and ipad with the kevinmd logo

    Learning the language of Patient and Doctor

    Heather Alva

More in Physician

  • Why some doctors age gracefully—and others grow bitter

    Patrick Hudson, MD
  • The hidden incentives driving frivolous malpractice lawsuits

    Howard Smith, MD
  • Mastering medical presentations: Elevating your impact

    Harvey Castro, MD, MBA
  • Marketing as a clinician isn’t about selling. It’s about trust.

    Kara Pepper, MD
  • How doctors took back control from hospital executives

    Gene Uzawa Dorio, MD
  • How art and science fueled one woman’s path to medicine

    Amy Avakian, MD
  • Most Popular

  • Past Week

    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • How to survive a broken health care system without losing yourself [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • What the research really says about infrared saunas

      Khushali Jhaveri, MD | Conditions
    • How the cycle of rage is affecting physicians—and how to break free

      Alexandra M.P. Brito, MD and Jennifer L. Hartwell, MD | Conditions
    • Why ADHD in adults is often missed—and why it matters [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • How to survive a broken health care system without losing yourself [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • What the research really says about infrared saunas

      Khushali Jhaveri, MD | Conditions
    • How the cycle of rage is affecting physicians—and how to break free

      Alexandra M.P. Brito, MD and Jennifer L. Hartwell, MD | Conditions
    • Why ADHD in adults is often missed—and why it matters [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

POLST and well-intentioned advance directives
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...