Criticalcare nurses care for many dying patients and their families; one out of every five Americans dies using ICU services.1 Critical care nurses are also among the best advocates for advanced directives and end-of-life decision making because they see the turmoil that occurs when no advance planning has been done.
For decades since the inception of laws creating advance directives (living will, power of attorney for healthcare) in 1976, critical care nurses have shared information about them with hospitalized patients and with the public in their communities.1 The federal Patient Self Determination Act (PSDA) enacted in 1990 was designed to increase the power of individual decision making about life sustaining treatment and improve use of advance directives. But it seemed to be too little and too late. In most locales, fewer than 25% of American citizens have completed and signed advance directives-and even if they have, it's often difficult for families to locate them or for healthcare providers to interpret and apply them when making clinical decisions.2
Using POLST to clarify end-of-life care
As an antidote to the difficulties encountered with advance directives, a relatively new and simple tool-the Physician Orders for Life-Sustaining Treatment, or POLST-has been devised to augment advance directives. It's becoming a model for state assurance that the wishes of the patient will be honored near the end of life.
By law in states that have adopted it, POLST is a portable document containing specific information about the patient's treatment wishes that must accompany him as he moves through the healthcare system. Because it has the authority of a physician's order, it must be followed by healthcare providers in the field and in the hospital.
The POLST Paradigm, as the concept is called, began in Oregon through the work of a coalition of healthcare providers from many disciplines and the public (http://www.ohsu.edu/ethics/polst/). It's spread to Washington, West Virginia, North Carolina, New York, and parts of Wisconsin and is under consideration within the legislatures in many states across the nation.
Nationwide, the impetus for POLST legislation often begins at the grassroots level with assistance from organizations with expertise in end-of-life care. These may include coalitions of hospices, nonprofit organizations, and activist groups.
How POLST works
The POLST form is a simple directive on card stock in bright colors that travels with the patient. The form is typically completed in a healthcare provider's office when the patient becomes seriously ill, such as with chronic obstructive pulmonary disease, cancer, or heart failure. After discussion with the patient or surrogate, a healthcare provider or social worker completes the form, which must then be signed by a physician or, in some states, a nurse practitioner or physician's assistant. Patient signature requirements vary among POLST Paradigm programs, but the National POLST Paradigm Initiative Task Force also recommends requiring the signature of the patient or surrogate (http://www.ohsu.edu/ethics/polst/).
The POLST Paradigm requires dialogue between the patient and healthcare provider. It's entirely voluntary and reflects any directions that have been provided in other advance directives. Either the patient or his healthcare provider may initiate the discussion about POLST, which is "designed to convert patient preferences for life-sustaining treatments into immediately actionable medical orders."3
POLST typically covers cardiopulmonary resuscitation (CPR), medical interventions, such as endotracheal intubation and mechanical ventilation, comfort measures only, antibiotics, and artificially administered nutrition. In some states, it may address decisions about transport to another facility (for example, nursing home to hospital) and a rationale for the decisions.
Research has shown that most Americans wish to die at home and that family stress is dramatically and significantly less when the patient's wishes are known in advance.4 Because the POLST document is designed to be long-lasting and portable across treatment settings, it can be posted on the patient's refrigerator or on the front of the patient's medical record, where it can be easily located by emergency medical technicians (EMTs) and other healthcare providers.
What the research shows
The basis of a POLST program in any state is to provide the patient with a means during severe illness to discuss with the family and healthcare provider key end-of-life issues and provide a mechanism to ensure adherence to his wishes. How well does POLST meet this goal? In Oregon, where POLST has been utilized for 12 years, the processes and outcomes associated with POLST have been examined carefully in many settings. In one study of nursing home residents with a POLST marked "do not resuscitate," "comfort measures only," and "transfer only if comfort measures fail," only 15% (180 residents) were transferred to a hospital temporarily; in most of those cases, the transfer was made because the nursing home couldn't control suffering. In accordance with their wishes, none of the 180 residents received ICU care, were placed on mechanical ventilation, or received CPR.5
Another Oregon study examined the experiences of 403 EMTs. Most (93%) found POLST to be useful in determining which treatments were appropriate when the patient was in cardiopulmonary arrest in the home, nursing home, or assisted living facility.6
The National Quality Forum has stated that "compared with other advance directives programs, POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals."7
How you can get involved
As educators and supporters of patient autonomy, critical care nurses value patient choice and respect for that choice in various settings. Involvement in state initiatives to develop and support POLST is one way for nurses to put their concern into action. The best way to get involved is to access the POLST Paradigm Web site (http://www.ohsu.edu/ethics/polst/). By placing the cursor over your own state, you can determine the status of POLST in your state. If your state has initiatives in place but hasn't yet enacted legislation, you'll find information about the coalitions and organizations involved. Contacting these lead organizations is the first step to being involved. For states with no POLST initiative, you'll find instructions for launching a program.
Moral distress is often experienced by critical care nurses when treating patients for whom treatment is futile or even harmful. Continued involvement in legislative and local efforts to honor advance care planning is one way to ensure that the perspectives of nurses on the front line are heard.
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