Physician Orders for Life Sustaining Treatment (POLST): a useful tool or just another burden?

How often have you been involved with or heard about an elderly sick person who is rushed to the Emergency Department and skillfully resuscitated, admitted to ICU then a few days later either dies in hospital or is returned to a skilled nursing facility or their home only to resume their death trajectory.

How often do we know the patients’ wishes for lifesustaining treatment and how often do the patients’ caregivers know their wishes? How often do we as physicians take the time to have a family conference to discover our patients’ wishes and preferences for care in the face of catastrophic and life threatening illness? How many third-party payers allow reimbursement for time spent on this most important part of caring for our patients?

Patients and their caregivers lack information about their prognosis in many instances of life threatening illness. As physicians we don’t want to take away hope in the face of uncertain prognosis, but we could say: “you have a very serious condition that could shorten your life. If the illness reaches a point that survival is unlikely regardless of treatment, do you want to continue to seek curative treatment or do you want to focus on comfort rather than longevity?” We would assure them that they do not have to answer these questions today, but should think about them and if they do give an answer, they can always change their mind.

Patients’ lack of information about terminal illness is so prevalent that in 2008, AB 2747, Berg. End-of-life care. became state law and is part of the Health and Safety Code. This law states that if a person diagnosed with potentially fatal illness requests comprehensive information about options and end-of-life care, we are obliged to provide them with this information or facilitate referral or transfer to another physician. An essential element of this information is their right to refusal of or withdrawal from life sustaining or disease targeted treatments. An important balancing element is the patient’s right to continue disease targeted and life sustaining treatments with or without palliative care.

The scope of AB 2747 highlights the importance of an Advance Directive. AB 2747 also highlights the need for a way to document and transfer the information along with the patient to different venues. Along comes AB 3000, Wolk. Healthcare decisions: life-sustaining treatment to meet this need. The key contribution of AB 3000 is Physician Orders for Life-Sustaining Treatment (POLST) created by the members of the California Coalition for Compassionate Care.

POLST is an order set to be printed on bright pink card paper meant to accompany the patient wherever they go. It can be copied and copies carry full force. It is endorsed by the Emergency Medical Services Authority and is HIPPA friendly.

Most importantly, it is a physicians order and protects health care providers who comply with the orders from criminal, civil and all other potential sanctions. The (POLST) card has four sections on the front:

A. CPR
B. MEDICAL INTERVENTIONS
C. ARTIFICIALLY ADMINISTERED NUTRITION
D. SIGNATURES AND SUMMARY OF MEDICAL
CONDITION

and on the back it has directions for use of the order set and contact information with the name, address and phone number of the Health Care Decision maker.

AB 3000 does not mandate the use of POLST but it does mandate that the orders be honored except in extraordinary situations such as requests for inappropriate therapies.

The patient or the Health Care Decision Maker can at any time void or change the Orders.

Rather than replacing the Advance Directive, POLST gives the decision maker a powerful implementation tool that will save physician’s time spent in dealing with problems created by lack of communication of preferences.

The California Coalition for Compassionate Care website http://www.finalchoices.calhealth.org/polst-hcp.html provides the POLST guidebook and forms as well as the complete text of AB 2747 and 3000.

---

Click here for a copy

Discharge Medication Reconciliation Order Form

Effective mid July, there will be a revision to the Discharge Medication Reconciliation Order Form that will improve ease and clarity in performing medication reconciliation when discharging patients. These revisions will reduce potential transcription errors and will help to improve Core Measure and NPSG outcomes.

The changes include:

• Making the inpatient medication page 2 a reference only form, deleting the requirement and ability to order from this page
• Making all discharge medication dose changes, deletions or additions on the first page that reference the Preadmission or Home medications
• Alpha sorting all the inpatient medications to allow for easier review by the physician

Any questions, feel free to contact Kathy Topp, Director of Education and Clinical Informatics at 802-2266

---

PHYSICIAN USE OF AJCC TNM STAGING

The American Joint Committee on Cancer (AJCC) is modifying reporting requirements with an effective date of January 1, 2010. The changes will allow a more individualized patient treatment plan and a better prediction of response. Therefore it is crucial for the physician to clearly document the AJCC stage of the patient in the medical record.

Physician documentation in the medical record of the AJCC stage, along with the clinically significant prognostic factors outlined by the AJCC, is an important communication tool between the physicians involved in the care of the patient and the cancer registry. Our Registrars are the gatekeepers for and custodians of essential high-quality cancer patient data that drives change. They provide the National Cancer Data Base (NCDB) data that contributes to the changes in the AJCC TNM.

The revision being implemented is an important step toward personalized medicine, a tailoring of medical treatment to the individual characteristics of each patient. Personalized medicine is a concept completely founded on evidence-based (data-driven) approaches. Data-driven decision-making requires high-quality data. The starting point of quality patient care is through accurate and complete physician documentation and AJCC staging. We appreciate your support and participation with these changes.

For further information on the required documentation in the medical record, please contact the cancer registry. (760) 940-3042.