Pandemic Journal (# 5): POLST (Provider Orders for Life-Sustaining Treatment)

This Pandemic should prompt everyone, and especially older people, to think about how they want to die and how they want their financial assets and liabilities handled after they are gone from this world. I already have reviewed my will, trust documents and health care directive and decided that no changes were necessary other than updating contact information for my health care agents.[1]

I also recently have discovered another important document that an individual should review and decide whether it is appropriate for him or her or anyone in their family to fill out and sign before that individual ever goes into a hospital emergency room.

That document is the POLST or Provider Orders for Life-Sustaining Treatment, which was created “to advance care planning for patients who are considered to be at risk for a life-threatening clinical event because they have a serious life-limiting medical condition, which may include advanced frailty.”[2]  The Minnesota form has the following sections with boxes to check the appropriate treatment:[3]

A. CARDIOPULMONARY RESUSCITATION (CPR) Patient has no pulse and is not breathing.

• Attempt Resuscitation / CPR (Note: selecting this requires selecting “Full Treatment” in Section B).
• Do Not Attempt Resuscitation / DNR (Allow Natural Death). When not in cardiopulmonary arrest, follow orders in B.

B. MEDICAL TREATMENTS Patient has pulse and/or is breathing.

• Full Treatment. Use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. All patients will receive comfort-focused treatments. TREATMENT PLAN: Full treatment including life support measures in the intensive care unit.
• Selective Treatment. Use medical treatment, antibiotics, IV fluids and cardiac monitor as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. All patients will receive comfort-focused treatments. TREATMENT PLAN: Provide basic medical treatments aimed at treating new or reversible illness.
• Comfort-Focused Treatment (Allow Natural Death). Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. TREATMENT PLAN: Maximize comfort through symptom management.

E. ADDITIONAL PATIENT PREFERENCES (OPTIONAL)

• ARTIFICIALLY ADMINISTERED NUTRITION Offer food by mouth if feasible. Long-term artificial nutrition by tube. Defined trial period of artificial nutrition by tube. No artificial nutrition by tube.
• ANTIBIOTICS Use IV/IM antibiotic treatment. Oral antibiotics only (no IV/IM). No antibiotics. Use other methods to relieve symptoms when possible.
• ADDITIONAL PATIENT PREFERENCES (g. dialysis, duration of intubation)

POLST was started in the early 1990s by a group of Oregon medical ethicists, and then in September 2004 the National POLST Advisory Panel (later known as the National POLST Paradigm Task Force and now known as The National POLST Office) was convened to establish quality standards for POLST forms and programs and to assist states in developing POLST as a model process. [4]

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[1] This blogger has decided to periodically post his reactions to living through this pandemic. Here are the earlier such posts to dwkcommentareis.com: Pandemic Journal (# 1): Kristof and Osterholm Analyses (Mar. 23, 2020); Pandemic Journal (# 2): Westminster Presbyterian Church Service (03/22/20)  (Mar. 24, 2020); Pandemic Journal (# 3): 1918 Flu (Mar. 27, 2020); Pandemic Journal (# 4): “Life” Poem (Mar. 28, 2020).

[2]  National POLST, POLST Fundamentals ; Sandler, Time for Death Panels? No. Care directives? Yes., StarTribune (Mar. 26, 2020).

[3] Minnesota Provider Orders for Life-Sustaining Treatment (POLST). Here is the national form.

[4]  National POLST, History.