Sourcebook : 7.7 Make Patient Preferences Accessible and Known to All Health Care Providers : 7.7.1 Case Study - Oregon's POLST - Physician Orders for Life-Sustaining Treatment

Oregon uses the one-page Physician Orders for Life-Sustaining Treatment (POLST) Document to help health care providers honor patients' treatment wishes. Printed on unmistakable bright pink card stock, the form is attached to the front of medical records in hospitals and nursing homes. The document is a physician order form that records patient preferences and treatment intentions and is meant to enhance the appropriateness and quality of care. The form contains specific orders on whether a patient wants to be resuscitated and lists any limits on medical interventions to be used - specifically, antibiotic use and feeding procedures. Physicians review the document with patients and families, but patients do not actually complete it; the POLST is not a substitute for a living will or durable power of attorney.

According to a 1998 study by the Center for Ethics in Health Care at Oregon Health Sciences University, POLST is effective at limiting unwanted treatments. Of 180 nursing home patients who had indicated DNR on their POLST, not one received CPR, was admitted to the ICU, or received ventilator support. Only 2 percent were hospitalized to extend life. Of the 38 people who died during the year of the study, 63 percent had an order for narcotics, and only 2 died in an acute care hospital.

Dr. Susan Tolle, director of the Center, says the study shows that "the POLST form focuses efforts on the patient's comfort, creating a positive plan that serves the patient." Tolle believes that several features of the form make it effective:

• It is standardized statewide, improving the likelihood that it will be recognized and respected.
• Because of its shocking pink color, it cannot be ignored and is easy to find.
• The orders to limit life-sustaining treatment are clearly printed on the front, making them easily located.
• The form is written in plain English, making it easy for staffs of nursing homes, home hospices, home health agencies, as well as covering physicians, to understand it.
• The specific language requiring comfort measures encourages attention to pain and suffering - and relieving both.

Tolle notes that another reason POLST is so effective is a five-year, statewide education initiative, as well as Oregon's commitment to providing resources to support patients dying at home.

The POLST was developed in response to concerns about problems in respecting DNR orders when patients were transferred from nursing homes to hospitals. The document is meant to reduce unwanted transfers and, for most patients, limit intensive medical interventions. To date, 175,000 forms have been distributed statewide, and hundreds more have been distributed around the country.

Oregon has made another important improvement by redefining the scope of practice for EMTs and first responders and for their supervising doctors. EMTs and others are now directed to respect patient wishes to life-sustaining treatments and to comply with physician orders, such as those in the POLST document.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved. For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].