• What is POLST?

    It stands for Physician Orders for Life Sustaining Treatment (POLST), and Helen Kao writes about hating the forms even as she uses them daily. She notes the importance of language and how it can hinder communication and decision making.

    By labeling this document “Physician Orders for Life-Sustaining Treatment” we imply that the interventions described in the form, should they be applied to you when you have “no pulse and [are] not breathing” (as detailed on the form) will be Life-Sustaining. So many of my patients, despite careful and thoughtful in-depth discussions I have with them prior to pulling out the POLST form, take pause when they see the title.

    Her suggestion for a change

    A far more neutral and preferable title for this critical document is Physician Orders for Scope of Treatment (or Medical Orders for Scope of Treatment ) as used in other states. Scope of treatment leaves no fuzzy terminology to be interpreted by the reader. It simply says that this document will tell readers, caregivers, providers, what types and levels of care an individual wants. It does away with the implication that using a POLST form means choosing death over life.

    Christian Sinclair, a palliative medicine physician from Missouri calls for evidence based improvement of such forms/tools.

    I live in one of the many states which is in the process of developing a program. In spite of the weaknesses of forms currently in use in other places, PO(L)ST/MO(L)ST remains a very helpful tool with new research continuing to back its utility. For instance, consider a recent study published in the Journal of the American Geriatrics Society which demonstrated high consistency between treatments provided to nursing facility residents and orders recorded on POLST forms. The study found that overall, POLST orders were consistent with treatments provided 94% of the time. Consistency rates were especially high for resuscitation orders. Consistency rates were slightly lower for antibiotic use and much more modest for feeding tubes use.

    Beneath the cultural and political noise about rationing and death panels, this is where the rubber meets the road, and we have no hope of a sustainable health care system without learning to confront death and limits in an open, and honest manner. Getting these forms correct is a part of that.

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    • Dating myself, as far back as residency in the 70s I objected to ‘DNR’ orders, because they clearly implied that we were going to not attempt an intervention that would likely be successful. I always wrote ‘DNAR’ for ‘do not attempt resuscitation’ and discussed it with patients and family as deciding whether or not to attempt something that was (in the contexts we were discussing) rarely successful, and often not useful even if temporarily successful.

      Same problem, different name.

      • @Peter Elias
        yes, thanks for sharing this. Language very important and we seem to have been bad it at for some time.

    • If I were to pick a name, it would be CAST for Collaborative Agreement for Scope of Treatment.

      (I would also like to see patients as voting members of all the bodies and groups that come up with protocols and algorithms and recommendations. We get pretty upset if we are not at the table with leadership/management when they make decisions that impact us. Why do we not understand that the same applies for patients?)

      P

    • @Peter Elias
      sounds reasonable. Plus, we need to begin to have these sorts of conversations or at least be aware that they are a reality long before we need to have them for ourselves.