Improving
Continuity of Care at the End of Life
A summary of the California POLST Project
The goal of this project is to establish the Physician’s Orders for Life Sustaining Treatment (POLST) paradigm as a recognized and widely-used tool in California to help ensure that patients’ treatment wishes at the end of life are honored.
Project Background
Frequently, advance directives, in which people specify their wishes for care at the end of life, do not live up to their promise. Completion rates are low. When completed, often the advance directive cannot be located when it is needed. The wording is often too vague to provide sufficient guidance for specific clinical situation that arises.
In the early 1990s, Oregon developed the POLST process to address challenges related to advance care planning, most commonly seen in frail and elderly patients. Since then, POLST has been adopted by West Virginia and Washington states, as well as parts of Wisconsin, Pennsylvania, New York, Utah, New Mexico, Michigan, Georgia, and Minnesota.
Hallmarks of POLST are (1) immediately actionable signed medical orders on a standardized form (2) orders that addresses a range of life-sustaining interventions as well as the patient’s preferred intensity of treatment for each intervention; (3) a brightly colored, clearly identifiable form (4) that is recognized, adopted, and honored across treatment settings.
Completion of the form is recommended for patients with a serious illness and life expectancy of a year or less.
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 two percent were hospitalized to extend life. Of the 38 people who died during the year, 63 percent had an order for pain medication, and only two died in an acute care hospital.
Activities
The California HealthCare Foundation (CHCF) has given the California Coalition for Compassionate $94,656 to analyze the legal and public policy environment in California that impact the adoption and use of POLST, to develop recommendations on the best approach for addressing any barriers that exist, and to convene and collaborate with stakeholders throughout the process to ensure thorough discussion and obtainment of stakeholder support.
In addition, CHCF has committed over $120,000 to establish POLST as a community practice in seven local communities around California. The seven sites selected are: