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The POLST conversation

February 20, 2017
by Pamela Tabar, Editor-in-Chief
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Much of the impetus in the long-term care (LTC) industry over the past decade has been on person-centered care, especially on the care and supports needed for a person to age well. But what about dying well?

Misconceptions still abound on documenting end-of-life decision-making, including what the various forms authorize. A resident might have a do not resuscitate (DNR) form, an advance directive, a living will, a Physicians Order for Life-Sustaining Treatment (POLST) form or all of the above. Or, more likely, perhaps none of the above.

The stats are sobering:

  • Most Americans lack knowledge about their end-of-life choices. [National Academies Dying in America report, 2014]
  • Fewer than 10 percent of Americans say they’d prefer to die in a hospital setting. [National Academies Dying in America report, 2014]
  • 82 percent of Californians say it’s important to put end-of-life wishes in writing, but only 23 percent have actually done so. [2012 California HealthCare Foundation survey]
  • 90 percent of people say talking about end-of-life care with their families is important, but only 27 percent have done so. [2013 Conversation Project national survey]

While hospice providers are leading the way for industry best practices, the concept of person-centered dying has not always been embraced by other senior care settings, notes the National Academies of Sciences, Engineering and Medicine’s landmark 2014 report, Dying in America. “People nearing the end of life often experience multiple transitions between healthcare settings—including high rates of apparently preventable hospitalizations—which can fragment the delivery of care and create burdens for patients and families,” the report notes. “Not only do most Americans lack knowledge about end-of-life care choices, but the health community and other leaders also have not fully utilized strategies to make that knowledge available, meaningful and relevant across diverse population groups. Efforts are needed to normalize conversations about death and dying.”

The push for POLST adoption stems from the need for an actionable document to guide emergency personnel, nursing home staff and hospitalists in what to do—and what not to do—when a resident has a life-threatening crisis. By its nature, the POLST form represents an actual order for or against specific treatments and is far more detailed than a DNR form. As senior care providers and families strive to tailor treatments to the residents’ own wishes, the need for documenting and constantly updating those decisions becomes key.

So far, state-based POLST initiatives have varied greatly. Currently, 21 states have some sort of POLST program in the works, but only Oregon, California and West Virginia have a mature program in place. Oregon has been a leader since 1991, due greatly to the work of Susan Tolle, MD, Professor of Medicine, Division of General Internal Medicine and Geriatrics at the Oregon Health & Science University (OHSU) and the administrative director of Oregon’s POLST program. “The seeds of acceptance for POLST have grown fast,” Tolle says. “Even if your facility is not using a POLST form right now, it’s highly likely in the next two years it will be available in your region because that’s what’s happening across the country.”

Who needs a POLST?

The POLST form isn’t for everyone in senior care, especially at intake. Many older adults are living healthy lives or managing chronic conditions well into their 80s, and they understandably welcome conversations about proactive wellness and the active life more than discussions about death. Provider care teams wanting to begin the POLST conversation should focus first on residents who have debilitating or terminal conditions, including those with dementia and those with a degenerative condition that is likely to result in a life-depending visit to the hospital, especially if those visits could become recurrent.

Case in point: Putting POLST into practice

St. Ann’s Community, Rochester, New York, is the first senior community in New York state to adopt the electronic registry of the medical orders for life-sustaining treatment, which is called eMOLST in New York. The nine-floor, nearly 400-bed community recently spent 8 weeks converting all its medical orders for life-sustaining treatment forms into electronic format over an 8-week period. St. Ann’s now uses the eMOLST form as one of the basic tools for discussing healthcare goals at intake and makes the form part of the treatment plan evaluation.

“My feeling is, if you live in a nursing home, you absolutely, positively should have an electronic MOLST,” says Diane Kane, MD, St. Ann’s chief medical officer and a 30-year geriatrician.

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