POLST in Care Transitions

The so-called Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is in the news because the Catholic bishops of Wisconsin have issued a warning against the use of POLST.

List of seven popular “interventions” for care transitions,; POLST is one of the interventions. (Slide is from a presentation on “Interact”, from the Health & Human Services Administration on Aging website. [click image to enlarge])
POLST and other advance directives play an important role in the Community-Based Care Transitions Program (CCTP) and Partnership for Patients discussed in a previous post here at Belbury Review.

In order to reduce hospitalizations within a community, participants in the care transitions demonstration projects generally use one of a handful of “intervention” programs. A few of those interventions appear on a useful diagram that is posted at the Administration on Aging website (see illustration at right).  Though the slide was part of a presentation on “Interact” — just one of the interventions  — it presents a good summary of some of the others. POLST is one of those interventions.

CFMC — the National Care Transitions QIO Support Center — is promoting POLST.  One of the tools they offer on their website is a flyer for POLST that was created by the QIO for Pennsylvania, Quality Insights of Pennsylvania.  Quality Insights is actually a program out of the West Virginia Medical Institute.  West Virginia was one of the first states to actively promote POLST, so it is not surprising that Quality Insights is promoting POLST.

A poster advertising POLST was created by the QIO of Pennsylvania and is offered by CFMC as a sample tool for care transitions projects across the country.

While some of the care transitions interventions focus on pressuring patients and families to be responsible for proper medication, symptom identification, doctors’ appointments and so forth, a number of the interventions focus on end-of-life decisions, DNRs, and advance care planning.  This is particularly true of interventions involving patients in nursing homes who are frail and might request another trip to the emergency room.

For example, the tool from Interact on “Tips for Starting and Conducting the Conversation” suggests framing the issue of CPR in the negative context:

 “Sometimes when peoples’ hearts stop, doctors and nurses try to delay
the dying process … Have you considered whether you would want this or not?”

The rest of the discussion contains carefully chosen “facts” to discourage life-saving measures; facts such as:

The possibility of surviving CPR in a nursing home is very low, and CPR
often results in broken ribs and the need for a respirator (“breathing machine”) in
an intensive care unit.

The Interact tool also discusses “Artificial Hydration/Nutrition” and the supposed dangers of feeding tubes.

These are but a few examples of POLST and end-of-life discussions prompted by the “care transitions” project.

Erik Fromme, MD, is a hospitalist at Oregon Health & Science University who specializes in palliative medicine and is frequent co-author with POLST’s developers.  In early 2011 he articulated how POLST and palliative medicine would take a role in “care transitions.”  In an article titled “Transitions in End-of-Life Care:  the Oregon Trail,” Fromme remarked that “transitions” is a malleable term; useful because it can take on a variety of meanings suitable to meet a number of objectives:

Transitions is a broad term that can refer to moving from one care setting to the next, changing goals of care, changing both care setting and goals (as happens with the transition to hospice care), or even death.

Fromme concludes:

Strong palliative care teams, statewide outreach and education, and programs like POLST allow hospitals and healthcare systems to support patients, families, and clinicians in the inner work of letting go.

Not all of the care transitions interventions focus on “letting go,” but coaching patients and families in end-of-life decisions is a key feature in many contexts.