I care for a homebound patient who's terminally ill and doesn't want any more hospital admissions. Is the so-called POLST program a good way to protect him from transport to a hospital if he becomes unresponsive, or would he be better off with an advance directive? - S.P., CALIF.
Advise him to have both. Like an advance directive, POLST (Physician Orders for Life-Sustaining Treatment) is intended to communicate a patient's end-of-life treatment preferences. But unlike an advance directive, POLST has the authority of a medical order.
A voluntary program, POLST is most appropriate for patients with a terminal illness who may die within a year. But it's not a substitute for an advance directive, which fulfills other functions. For example, it may designate a surrogate to speak for the patient if he's incapacitated. If available, the advance directive should accompany the POLST form.
How does POLST work? After thoroughly discussing treatment preferences with the patient or his surrogate, a physician (or, in some states, a nurse practitioner or physician assistant) completes and signs the form. The patient's signature is also strongly recommended.
A patient living at home should post the brightly colored POLST form on his refrigerator so it can be easily seen by emergency medical technicians (EMTs), who are required to honor its directives. For example, the form provides explicit directions for EMTs about the patient's resuscitation status if he's apneic and pulseless. It also includes directions about transport and other interventions, such as whether he wishes to receive enteral feedings or antibiotics.
Originating in Oregon, the POLST Paradigm program is now up and running in many states across the nation, including yours. Some details vary, but all programs follow certain guidelines endorsed by the National POLST Paradigm Initiative Task Force. Here are some examples:
* The form must constitute a set of medical orders and be signed and dated by a physician or designated prescriber.
* The form must be a uniform and uniquely identifiable color (typically bright pink) within the state or region where it's valid.
* The form accompanies the patient across care settings.
* The program must include provisions for educating healthcare professionals about the program's goals and for ongoing monitoring.
Healthcare professionals and patients can find out whether a POLST program exists in their state by visiting http://www.polst.org.