POLST is a physician order for life-sustaining treatment, which is called a medical order for life-sustaining treatment in some states. This form is created during a conversation with a medical provider and lays out the patient’s end-of-life wishes. It is considered a medical order, and is most useful in times of emergency. Typically, POLST or MOLST forms are intended for patients who have a life expectancy of 1 year or less, and the POLST is a doctor’s order for the specific instructions the patient has given the physician about what to do in possible future situations.
- IF you have no pulse and are not breathing, do you want a CPR or DNR order?
- If you are not in cardiopulmonary arrest, then this item is not an issue. If you are, however, then making choices in advance of need is helpful. Resuscitation attempts to restart the heartbeat and breathing of a person who has no heartbeat and has stopped breathing. Typically this involved “mouth-to-mouth” breathing and forceful pressure on the chest, to try to restart the heart. Resuscitation may also involve electric shock (defibrillation) or a plastic tube down the throat into the windpipe to assist breathing (intubation).
- If you have a pulse and/or are breathing, what Medical Interventions do you want?
- Comfort Measures Only, the focus of care is on the main goal of keeping the patient comfortable. Instead of on medical intervention that may prolong life, use of oxygen, suction and manual treatment of airway obstruction are done as needed for comfort, but you will not be transferred to hospital for life-sustaining treatment, unless your comfort needs cannot be met in the current location.
- Limited additional interventions with selective treatment – include the care described above, plus medical treatment, IV fluids and cardiac monitor as indicated, but not intubation, advanced airway interventions or mechanical ventilation; you will be transferred to the hospital if indicated, but avoid intensive care.
- Full Treatment – includes the care described above, plus intubation, advanced airway interventions, mechanical ventilation and cardioversion as indicated; you will be transferred to the hospital if indicated, including intensive care.
- Do you want Artificially Administered Nutrition?
- Medical staff always offer food by mouth, if feasible. But sometimes that is not possible. For example, when a dementia patient loses the ability to swallow, then other choices may need to be made. Fluids and liquid nutrients (formula) can be given through a tube in the nose that goes into the stomach or through a tube placed directly into the stomach by a surgical procedure.
- Some people want no artificial nutrition by tube ever.
- Others want a defined trial period for artificial nutrition by tube.
- Still others want long-term artificial nutrition by tube.
- Medical staff always offer food by mouth, if feasible. But sometimes that is not possible. For example, when a dementia patient loses the ability to swallow, then other choices may need to be made. Fluids and liquid nutrients (formula) can be given through a tube in the nose that goes into the stomach or through a tube placed directly into the stomach by a surgical procedure.
POLST vs. AD
Besides a POLST form, advance directives (ADs) can be used to allow patients to communicate what their goals of care and preferred treatments would be if they were unable to speak for themselves. There are two main types of ADs: living wills and medical power of attorney.
- A living will is a document in which the patient specifies which treatments they would want if they could no longer express their own wishes.
- Medical power of attorney differs in that the patient does not necessarily specify which treatments they would want. rather, the patient designates someone else to make decisions for them if they are unable to do so.
Supporting the patient in decision-making with regard to advanced care planning is an extremely important component of palliative care nursing. Advanced care planning should, ideally, begin before the late stages of a terminal illness; it is difficult for patients and loved ones to consider advanced care planning in the setting of acute decompensation. Advanced care planning should occur over the course of several conversations to allow patients time to reflect and process what, for most patients, are emotionally challenging issues. Planning should address the patient’s goals with regard to life-sustaining therapy, such as code status, preparation for the possibility of the patient becoming incapable of decision-making, and a designated proxy for decision-making if the patient is unable to do so. It usually provides a great deal of relief to both patients and loved ones when end-of-life decisions are made ahead of time in keeping with the patient’s values and goals.
