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Analysis

5 Keys to Honoring POLST Directives in Emergency Departments

By Christopher Cheney  
   March 29, 2019

Engaging patients and family members is crucial when there are documents specifying physician directives for life-threatening conditions.

For clinicians, there are a handful of approaches to working with physician orders for life-sustaining treatment (POLST) documents in the emergency department setting, according to a recent article in the Annals of Emergency Medicine.

POLST forms are available across the country. Compared to living wills and durable power of attorney documents, POLST forms have been associated with significantly higher decreased odds of resuscitation attempts in the field and increased odds of out-of-hospital death for patients with "comfort measures only" directives.

"POLST forms are more useful than CPR directives in that they describe important broader end-of-life treatment choices than just whether to receive CPR attempts. For example, some patients may not want to go to the ICU; they may not want intubation," the author of the Annals of Emergency Medicine article, Jean Abbott, MD, MH, wrote.

Clinicians should take five approaches to working with POLST forms in the emergency department setting, according to Abbott, who is a professor emerita at the Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora.

1. Supporting emergency medical service workers
 

Abbott recently told HealthLeaders that EMS personnel are obligated to honor POLST documents but emergency departments are better equipped to interpret the forms as well as the care preferences of patients and family members. "When a family is overwhelmed enough to call 911, EMS should respond and bring the patient to the hospital. The ED is the place to sort out how to best honor a patient's wishes," she said.

The goal for EMS and ED staff should be to narrow the gap between the care that is provided and the patient's care preferences, Abbott said. "I have done a significant amount of training both with EMS and the ED to get them to a better place than, 'Well, I'll just do everything and if the patient survives, they can just figure out what to do upstairs.'"

2. Honoring POLST orders for CPR and airway management
 

Even in crisis conditions, ED clinicians should check the "yes" and "no" orders at the top of POLST documents for CPR and intubation, Abbott said. "Though not usually part of the ED situation, there are starting to be lawsuits when clear advance directives—usually in the form of the orders associated with POLST rather than more vague wishes expressed in other advance directives—are ignored."

3. Using POLST information to engage the patient and family members
 

After the initial crisis has been stabilized, ED clinicians should use POLST forms to engage patients and family members in a discussion about care preferences, Abbott said.

"There is no substitute for a conversation with patients and families to discern the meaning behind various choices—would they want antibiotics for an episode of presumed sepsis, would they want vasopressors for low blood pressure, etc. Much of those choices depend on where the patient is in the arc of their life—do they want a robust attempt to restore them to their pre-crisis state, or was their life already very difficult and they would lean more toward gentle interventions."

4. Considering disposition strategies that align with patient wishes
 

Based in information in POLST forms, ED clinicians can help patients or their surrogates to establish an action plan for hospital-based care, Abbott wrote in her Annals of Emergency Medicine article.

"Broaching the concept of, for instance, a time-limited trial or of revisiting interventions started in the ED may help the admitting team to later suggest stopping interventions that are not successful in restoring the patient to an acceptable quality of living," she wrote.

5. Preparing patients and families for difficult intervention questions
 

ED clinicians are well-suited for laying the foundation for discussions about intervention dilemmas, Abbott wrote.

"The ED role includes good documentation and robust communication with admitting teams. The electronic health record note should include topics broached, who was present, and what wishes and intent might have been clarified by the ED team. Palliative care consultation can and should be initiated when appropriate from the ED," she wrote.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Adherence to POLST form directives is higher than for living wills and durable power of attorney documents.

POLST forms have broader scope than CPR directives.

Emergency department clinicians can use POLST forms to help patients and family members craft action plans for hospital-based care.


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