Who should have a POLST?

Completing a POLST form is voluntary for the patient or legal medical decision maker. POLST is intended for individuals with advanced illness, serious life-limiting medical conditions, or advanced frailty. The health care professional (M.D./D.O.) may use several questions to determine if a POLST form is warranted. If the answer is “Yes” to any of these questions, the patient may have a condition that warrants the completion of a POLST form. A POLST form may be completed based on a deteriorating irreversible health condition. 

 

• Would you be surprised if the individual died in the next 1-2 years?

• Does the patient have a disease process that is in an advanced stage, such as advanced lung, renal, liver, or neurodegenerative disease (e.g., Dementia, Parkinson’s disease, ALS), advanced frailty, severe heart disease, metastatic cancer, and/or malignant brain tumor?

• Is the patient experiencing a significant decline in health (such as frequent aspiration pneumonias)?

• Is the patient in a palliative care, hospice program, or skilled nursing facility?

• Has this patient’s level of functioning become more severely impaired because of a deteriorating health condition when intervention will not significantly impact the process of decline?
   

Does a POLST form replace a Do-Not-Resuscitate (DNR) order?

A better question might be “Does POLST identify DNR preferences?” Yes — but it does more. A POLST form provides additional information that helps emergency personnel determine what treatments they should provide to a patient. Rather than automatically going to the hospital, a POLST may help keep the patient comfortable where they are located, if that is the treatment level they have chosen.

 

Like a DNR, a POLST form lets EMS know whether or not the patient wants CPR. DNR orders only apply when a person does not have a pulse, is not breathing and is unresponsive. However, in most medical emergencies, a person does have a pulse, is breathing or is responsive. That’s where POLST is different.

A POLST form provides more information to emergency personnel than a DNR by indicating that:

1. The patient still wants full treatment, meaning that they want to go to the hospital and that all treatment options should be considered, including use of a breathing machine;

2. The patient wants limited interventions, meaning that they want basic medical treatments but wish to avoid the intensive care unit (ICU); or

3. The patient just wants comfort measures meaning that they do not wish to go to the hospital but want to be made comfortable wherever they are living.

 

This additional section about desired medical treatments that a POLST form provides is incredibly important. Research has shown that, when someone completes a DNR, health care professionals often assume the patient wants less treatment. Research looking at POLST forms in Oregon shows that that is not the case: approximately half of patients who complete a POLST form in Oregon indicating that they do not want CPR also show that they want full treatment or limited interventions (or a higher treatment level).

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Are POLST forms still to be faxed to local fire departments/EMS offices like we did with Comfort One?

Yes, if accompanied by a HIPPA compliant confidentiality coversheet.

Initial communication in the POLST roll out advised that we should not fax AK POLST forms—that has been reviewed and is now decided to allow POLST forms to be faxed to patient’s local EMS/dispatch. This only needs to be done with POLST forms that indicate DNR as POLST orders indicating to provide CPR and full treatment are the default standard of care and would not impact EMS response.

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Can a POLST be used for patients with significant physical and/or developmental disabilities, and/or significant mental health conditions who are near the end-of-life?

Yes. However, patients with disabilities are at risk of bias resulting in under-treatment and/or have their chronic health conditions mistaken for illnesses or conditions nearing the end of life. The challenge to the health care professional is to discern when the patient is transitioning from a stable chronic disability to a more advanced phase of their illness. Involvement of their legal health care decision throughout the POLST conversation will help assure provision of high-quality care for the end of their life.

 

Can a POLST be used for individuals with guardians?

Yes. A guardian is the legal representative of the patient and should participate in a POLST discussion. Physicians may sign a POLST that includes limitations of treatment when the patient’s guardian offers a non-opposition to their recommendations for withholding life-saving or life-sustaining treatment.

 

What decisions are captured within POLST?

• Cardiopulmonary Resuscitation

• Medical Interventions

  • Full Treatment

  • Selective Treatment

  • Comfort-Focused Treatment

 

Does POLST replace advance directives?

No. The POLST form complements an Advance Directive and does not replace that document. An Advance Directive is still necessary to appoint a chosen legal healthcare decision maker, and is recommended for all adults, regardless of their health status. Use of the POLST form is designed for persons with advanced illness, serious life-limiting medical conditions, and/or advanced frailty.

 

The POLST form is designed to direct medical treatment in acute situations through specific medical orders addressing defined medical interventions. Since these orders are followed in emergent conditions, the POLST should reflect what the patient would want now in their current state of health.

 

The focus of the Advance Directive is to document future health care instructions for patients who no longer can speak for themselves.

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How should POLST a form be completed?

The POLST form is intended for the patient to complete in consultation with their physician supported by other healthcare clinicians. If the patient is not fully capable of making decisions, the surrogate/health care decision-maker as appointed in the Advance Directive is the legally recognized surrogate and discussions should occur with this person. It is prudent for the signer to review the Advance Directive and verify its validity. The surrogate/health care decision-maker has the legal right to accept or refuse medical treatments for the patient as defined by Alaska Statute.

 

What if a patient is unable, is incapacitated, and/or lacks medical decision-making capacity to have this conversation?

The legal healthcare decision maker can act as a surrogate decision maker.

 

If the patient does not have an Advance Directive with their chosen legal healthcare decision-maker noted, AS 13.52.030 identifies the appropriate surrogate decision makers that may be invited to speak on the incapacitated patient’s behalf or provide input into treatment options. If the designee is not reasonably available, Alaska law defines the classes of patient family who may act as surrogate in AS 13.52.030 (c).

 

If none of the persons identified in the statute is available, then life-sustaining procedures may be withheld or withdrawn upon the direction and under the supervision of the attending physician (some health systems have additional procedures for decision making in the care of those without a surrogate/health care decision-maker). Facility ethics committees or institutional policy may provide additional guidance for those who do not have a surrogate/health care decision-maker.

 

Is a patient or their legal healthcare decision-maker signature required to be valid?

No, not in Alaska. The first statement in this area reinforces that this form is voluntary and indicates that the patient has discussed treatment options and goals of care with their provider. The patient signature is not required; however, it is highly encouraged that the patient sign this form to confirm that the document accurately reflects the patient’s preferences. It is understood that most states require a patient signature on this form, and the form may not be honored in other states without the patient’s signature included.

 

Can a physician's verbal order be obtained for the completion of POLST?

Yes. A verbal order is also acceptable, with a follow-up signature, in accordance with the facility’s verbal orders policy. Note: forms may be completed electronically and signed using an electronic signature.

 

Does a POLST expire?

No. The final statement on Page 1 indicates “This form does not expire.”

 

When should a POLST be updated?

While this form and the orders therein do not expire, it is vital that the physician or his/her designee reviews this form regularly with the patient or patient’s representative.

 

Review to verify continued accuracy should occur at the following intervals:

· When the patient is transferred from one care setting or level to another

· Has a substantial change in health status

· Changes primary provider

· Changes his/her treatment preferences or goals of care
 

The POLST Form cannot be modified. If changes are needed, the current form must be voided and a new form created.

 

What do you do with a completed POLST?

Since POLST orders should always be completed in the context of the medical encounter, the recommendation is that the health care team take responsibility for ensuring the POLST is properly stored and is retrievable when needed.

The following are best practices for ensuring POLST can be found and honored:

• Ensure each completed POLST is scanned into all electronic medical records.

• Ideally, emergency medical services will have access to the electronic version of POLST or can quickly access the information on the POLST

• Instruct the individual, or their health care agent as well as any responsible caregiver or family member, about how to store the original of the POLST. This includes:

  • Suggest place where the individuals lives where it can be quickly located, such as next to the entry way or on a refrigerator

  • Make copies for all responsible parties who may be called in the event of an emergency for the individual

• Ensure that staff in every setting are trained to look for and honor the POLST orders.

 

How do you complete the POLST when a patient or legal health care decision-maker has limited English proficiency?

Health care interpreter services should be used when the patient and/or patient representative has limited English proficiency. The signed version of the POLST form must remain in English so that emergency medical personnel can understand and follow the orders.

 

What if a section in a POLST is blank or missing?

Any incomplete section of POLST implies full treatment for that section. Follow the directions on all completed sections. If a copy of a POLST only contains the front side, it is recommended to locate the original to ensure all the individual’s preferences and decisions are captures in the medical record. A POLST is invalid without the signature of the physician.

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How do you void a POLST form?

A patient with capacity, or the legal healthcare decision-maker for a patient without capacity, can void the form. This is done when the patient or legal healthcare decision-maker no longer wishes to have a POLST form, or when the form no longer accurately reflects patient wishes and needs to be updated.

 

Alaska does not currently have a POLST Registry; until one is established:

• Draw a line through Page 1 of the form, write VOID in large letters, and fax to all appropriate healthcare facilities that may have copies.

• Educate the patient or legal healthcare decision maker to verify that all healthcare facilities know it has been voided.

 

What should you do when transferring a patient with a POLST form?

For patients in institutional settings, the POLST form should accompany the patient upon transfer from one setting to another. A copy of the POLST form should be kept in the individual's medical record. HIPAA permits disclosure of POLST orders to other health care professionals across treatment settings. Copies of the POLST form are valid and should be honored by EMS and other professionals.

 

Is AK POLST honored in other states and vice versa?

Most states, including Alaska, allow honoring out of state POLST forms if that form complies with the laws of the state in use.  For honoring out-of-state POLST forms in AK, this means the form must be signed by a physician to be a valid medical order in  Alaska (Alaska Statute 13.52.150).   For traveling out-of-state with an Alaska POLST it is recommended to have the patient/proxy sign the document since this is required in most other states to be a legal POLST order.

 

How do you navigate disputes regarding POLST?

Sometimes disputes arise regarding existing treatment orders on a POLST form for a patient who no longer has decision-making capacity. These disputes may center on who has decision making authority and/or what the decision(s) should be. For example, a family member is requesting treatment that is inconsistent with the existing POLST form.

 

For EMS, it is recommended to clarify the family's understanding of the POLST form and contacting your On-Line Medical Control, if possible. If conflict continues to exist, transport to a hospital where there is more time to thoughtfully address the conflict.

 

For health care facilities and organizations, if a family dispute arises concerning the validity of a POLST form, it is recommended that you follow the facility or organization policy regarding surrogate/health care decision-making.

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Is the physician who signs the POLST form responsible for the completion of the patient's death certificate after death occurs?

The person who is responsible for completing and signing the death certificate is the physician who oversaw the patient's care for the illness or condition that led to the patient's death. 

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What if the patient has a Comfort One and a POLST on file, or if they have two POLST forms and neither is voided?
The Comfort One or POLST form that was written most recently are the medical orders to follow in an emergency. While it is recommended to have old POLST forms voided when completing a new form, one can expect there will still be copies of the initial form with patients, families, in medical records, etc, so be sure look for the most recent form. In June 2022, the state will no longer provide new Comfort One forms, however completed Comfort One forms will continue to be honored. While it is recommended to ask patients to update their Comfort One to a POLST for the added clarity around their wishes, this is not required.

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How does the AK POLST form affect the Alaska MOST form?

It is recommended that clinicians and health care facilities transition from MOST to AK POLST.

 

To address the deficiencies of the Comfort One (needing a way to document pre-arrest life-sustaining treatment preferences), the Alaska MOST taskforce developed the Alaska MOST form. However, the form was never legislated as a state-wide medical order, therefor, there are no state protocols instructing health care professionals to follow the MOST orders and no provisions for immunity from civil and criminal liability for health care professionals following the order. 

 

Since its development, the AK MOST has been used in different ways across the state. Some long-term care and skilled nursing facilities have adopted the AK MOST form as their in-facility DNR and life-sustaining treatment orders. Other communities have used the MOST form as a communication tool to convey a patient’s wishes across care sites. For clinicians and facilities that are utilizing the MOST form it is recommended to transition to AK POLST form use instead.

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Where do I get a POLST form? Does it have to be on special paper?

POLST forms can be downloaded from this site. If you keep a pdf of the POLST form for general us, check back occasionally to be sure you have the most up to date version. POLST form printing does not require special paper or use of colors.

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Does the AK POLST serve as an expected home death form?

Similar to the Comfort One, the POLST form can also convey to law enforcement that the patient has a life-limiting condition where a home death may be expected.

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Are Advance Practice Registered Nurses (APRN), and Physician Assistants (PA) legally permitted to sign an Alaska POLST form?

Yes, Advanced Practitioner Registered Nurses (APRN), and Physician Assistants (PA) are now granted legal authorizing to sign the current Alaska POLST form.  This change was made possible by House Bill 392 (HB392), which was signed into law on 10/5/2022 with an Effective Date of 11/8/2022.  HB392 amended AS 13.52.65, authorizing Alaska licensed APRNs and PAs to sign Do-Not-Resuscitate (DNR) orders, despite the fact that Alaska Regulation, 7 AAC 16.010 does not currently reflect this change. 

 

When can we expect the update 7 AAC 16.010, POLST form, and the POLST program guide be updated?

When new or revised Alaska Statutes are implemented, updates to the Alaska Administrative Code (Regulations) follow and take time for completion.   In this instance, the POLST form and the program guide are presently adopted by reference into the regulation itself, necessitating any changes to be included in the Regulation update process, which includes a publicly available written comment period.  Once the updated Regulation package is finalized and signed by the Lt. Governor, it will become effective.  The entire process is expected to be completed before December 31, 2023.