Open for Interpretation: POLST Forms Versus DNRs

When it comes to end-of-life decision making, most people are very specific about their personal preferences, according to a recent article at OregonLive.com. But a standard DNR (Do Not Resuscitate) order falls short, leaving caregivers with the burden of interpreting their loved one’s wishes. DNRs are currently the standard used by most hospitals and skilled nursing facilities, but a growing movement is slowly replacing the DNR: POLST forms.

POLST forms go beyond the DNR

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POLST (Physician Orders for Life-Sustaining Treatment) forms go above and beyond, outlining specific measures to be taken under different circumstances. A person can specify, for example, that he wants to be treated with antibiotics for an infection but does not want a feeding tube. POLST forms have actually been around since the 1990s (and were developed in Oregon), but communities across the country have been implementing the program in recent years.

POLST: Overcoming limitations of DNRs and advance directives

Standard DNRs and advance directives can be difficult to locate in an emergency. POLST forms, on the other hand, were originally designed to be brightly-colored and travel with a patient. If a resident in a skilled nursing facility or assisted living facility is transferred to the hospital, for instance, the POLST form accompanied the patient so there’s no ambiguity regarding the individual’s preferences.

Today, however, the state of Oregon relies on an electronic database established in 2009 so practitioners have immediate access to a patient’s POLST form. And patients are free to completely revoke or modify their POLST forms at any time. To date, more than 70,000 Oregon residents have filed a POLST form, a dozen states have implemented POLST orders and 22 additional states have plans to do so.

Code status tells little about individual preferences

Standard DNRs (or advance directives) tend to focus solely on a person’s code status: Do you want to be resuscitated in the event that your heart stops beating, for instance. The answer for many folks is no, but these orders fail to move beyond this to specify individual circumstances and various types of treatment¬† options that could provide comfort or prolong life.

The problem is that many physicians and emergency personnel have a tendency to over-interpret a no-code status, meaning if they’re treating an individual with a DNR, they also won’t consider other treatment options, such as antibiotics, feeding tubes, comfort care or hospitalization. Under these circumstances, some individuals failed to receive treatment they may have wanted, or ended up receiving life-sustaining measures they would have opted out of if given the choice.

Researchers from Oregon found that about 72 percent of people in the registry (a total of 25,000 individuals) didn’t want CPR, but were in favor of other measures, including hospitalization, temporary feeding tubes and antibiotics to treat infection. In prior studies, it was discovered that patients with a no-code status were less likely to receive antibiotics or to be hospitalized, and in some cases, physicians were less likely to order lab work.

According to Dr. Steven Zweig, professor at the University of Missouri-Columbia School of Medicine, says POLST forms help create meaningful conversations about end-of-life care, noting that standard DNRs over-emphasize CPR without drilling down to other important preferences.

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4 Responses to “Open for Interpretation: POLST Forms Versus DNRs”

  1. Joseph Earll says:

    Does Missouri have an approved POLST form? If so, where can one find a copy, on or off-line?

  2. Angela Stringfellow says:

    Hi Joseph,

    I looked this up, and from what I can see it looks like Missouri uses a different program/form called a TPOPP form which works in a similar manner. You can read more about that here: http://www.nolo.com/legal-encyclopedia/missouris-transportable-physician-orders-patient-preferences-tpopp-form.html

    I hope this is helpful! Please don’t hesitate to reach out to us should you have any questions at all. We’re happy to help!
    Angela

  3. Carol Eblen says:

    I think there might be legal problems with the POLST form in Missouri wherein the law requires two witnesses to DNR code status which is entered into a patient’s Hospital chart — which then does protect the informed consent doctrine.

    Informed consent is a problem of the POLST documents because of the influence of third parties, like resident physicians or social workers, who help the elderly/disabled to prepare these documents that act as advanced directives in and out of the hospital concerning treatments wanted and not wanted when death is imminent (meaning 6 months –12 months or what).

  4. Angela Stringfellow says:

    Hi Carol,

    Thanks for your insights! The POLST program is definitely in its infancy. And as you point out, there are obstacles to implementing it in some states. I think there’s definitely a clear need for a consistent document that follows individuals and clearly outlines their preferences for end-of-life and life-sustaining care. How we actually get there is still an ongoing debate.

    Thanks for reading and sharing your information!
    Angela

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