Nancy D. Zionts Judith S. Black, MD, MHA Chief Operating Officer

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Nancy D. Zionts Judith S. Black, MD, MHA Chief Operating Officer
Nancy D. Zionts
Chief Operating Officer
Chief Program Officer
Judith S. Black, MD, MHA
Medical Director,
Senior Markets
Jewish Healthcare Foundation
Highmark, Inc.
© 2015 Jewish Healthcare Foundation
Why We Started Closure
High Intensity of End-of-Life Care in Last 6 Months of Life (2005)
Comparison to a Community with a Strategy
Hospital days
In-patient Medicare reimbursements
% admitted to intensive care during
final hospitalization
% admitted to intensive care
% of hospitalized Medicare deaths
% spending seven or more days in
intensive care
Data extracted from: The Dartmouth Atlas of Health Care, Center for the Evaluative Clinical Sciences at
Dartmouth Medical School; Population-based rates for geographic regions
Hospice days per decedent during
the last 6 months of life (2001-2005)
Data extracted from: The Dartmouth Atlas of Health Care, Center for the Evaluative Clinical Sciences at
Dartmouth Medical School; Provider-based rates for geographic regions;
© 2015 Jewish Healthcare Foundation
Specialist: “I saved
him, but I am not sure
I did him any favors.
He didn’t think so,
nor did his wife.”
Clergy: “Do care and
cure have to be
united? I can accept
supporting death as
Family: “Too many
decisions are made at
the moment of acute
terror. We should talk
Social Worker: “Death
is still seen as a
failure. Our docs can’t
deal with it.”
© 2015 Jewish Healthcare Foundation
Patients and families suffering at end-of-life and
receiving high intensity services at a high cost
The general public unaware of, misinformed
about, and under-utilizes palliative care and other
end-of-life planning and care resources
Healthcare systems, reimbursements and policies
that do not support good end of life outcomes
© 2015 Jewish Healthcare Foundation
Patients and loved ones are informed about
choices and challenges
Resources and support systems are widely
accessible in all settings, understood by
physicians and families, and appropriately
Curricula and planning tools are widely available
for professionals and community members
End-of-life issues are openly discussed, with the
experience viewed as meaningful and uplifting,
whenever possible
© 2015 Jewish Healthcare Foundation
There are many types of
“Conversations” around end
of life
© 2015 Jewish Healthcare Foundation
POLST (Physician Orders for Life Sustaining
Treatment) – between doctors and patients
The Conversation Project – individuals telling
their stories
Advanced Care Planning – families,
physicians, sometimes attorneys
Five Wishes – patient driven
© 2015 Jewish Healthcare Foundation
Changing Expectations for Care at End of Life
© 2015 Jewish Healthcare Foundation
Not a single conversation.
Consists of a structured series of Community
Deliberately involved a range of
participants/participant types/sites
Results in an action plan and changes in
processes and culture
© 2015 Jewish Healthcare Foundation
Society – What is a “good”
death; can we consider death as a
part of the lifecycle?
– Why do we limit
advanced-care planning palliative
care options? Where is the
guidance and support?
System – Why is the “default”
Provider – Where is the training
setting cure vs. care?
Why does reimbursement
incentivize treatment
over palliative care?
and support to admit “failure,”
and to help families transition
from “cure” to “care”? How do I
access other resources to support
patients and families
through their life
© 2015 Jewish Healthcare Foundation
Closure Participants:
Attended Six Monthly Sessions/ 18 Hours
Physicians and
Registered Nurses
Service Providers
“Family” Caregivers
•AIDS Specialists
•Adult Day Care
•Home Healthcare /
Direct Care Workers
•Estate and Financial
•Hospice Care
•Palliative Care
•Senior Service
•Critical Care
•Emergency Care
•Family Medicine
•Hospice Care
•Social Workers
•Long-Term Care
•Palliative Care
•Pediatric Palliative
•Primary Care
© 2015 Jewish Healthcare Foundation
Closure : Conversations About End-of-Life
Overview of Issues: How
do most Americans die?
What makes a “good” endof-life experience for
patients, families and
The Planning Tool Kit:
What are the essential
documents and resources
for successful preparation?
Who helps with this?
Values: How do ethical
issues and religious
customs influence end-oflife decisions?
The Family and Providers
Experiences: Can
caregivers and providers
listen and learn from each
other’s perspectives and
Resources and
Implementation: When
should we access palliative
care services and hospice
Planning for Culture
An Action Agenda
© 2015 Jewish Healthcare Foundation
To provide a mechanism to communicate patient preferences
for end-of-life treatment across treatment settings.
© 2015 Jewish Healthcare Foundation
Pennsylvania Form
clarifies type of
resuscitation. Do
Not Attempt
assists clinicians in
odds about success
instruction on
when to
transfer to
hospital and
use of intensive
IV fluids in
Options give
people the
choice to
decide later
since issue of
when to use
antibiotics is
hydration and
artificial nutrition
both found here
preferences is
If any section left
unmarked, the
highest level of
treatment must
be provided
© 2015 Jewish Healthcare Foundation
In choosing CPR or DNR, patients need understanding of the
Television portrayal of CPR unrealistic with 66% surviving. In
real life for elderly patients
 22% may survive initial resuscitation
 10-17% may survive to discharge, most with impaired
Chronic illness, more than age, determines prognosis in the
◦ With chronic illness, average survival rate less than 5%.
◦ With advanced illness, survival rates are often less than 1%
Annals Int Med 1989; 111:199-205;
NEJM.1996; 334(24):1578-82.
JAMA 1990; 264:2109-2110
© 2015 Jewish Healthcare Foundation
If choosing “Attempt Resuscitation / CPR” in Section A,
“Full Treatment” is required for Section B, Medical
• It is not appropriate to request “Attempt CPR” and
“Comfort Measures Only”
• If a person wants CPR, they must be willing to have
ACLS (Advanced Cardiac Life Support) guidelines
followed, which usually includes intubation and care in
the ICU
© 2015 Jewish Healthcare Foundation
“Do Not Attempt Resuscitation / DNR” may be
chosen with any of the medical interventions in
Section B
“DNR” with “Full Treatment”
◦ Can choose to receive aggressive medical
interventions, but doesn’t want to be resuscitated if
found without a pulse or not breathing (they have
© 2015 Jewish Healthcare Foundation
Comfort Measures
Limited Interventions
Full Treatment*
*Consider time/prognosis factors under “Full Treatment”
“Defined trial period. Do not keep on prolonged life support.”
Materials adapted and used with permission from the Coalition for
Compassionate Care of California, www.coalitionCCC.org
© 2015 Jewish Healthcare Foundation
Pennsylvania Form 2nd Side
This side includes:
Surrogate Contact
A line for the signature
of a POLST Facilitator
who completes the form
© 2015 Jewish Healthcare Foundation
How do you
start the conversation?
© 2015 Jewish Healthcare Foundation
What has she been told to expect?
◦ Her goals and understanding
Her perceptions of what has happened
What does she see in her future
◦ What is most important to her for the time that she
What would she like to know
© 2015 Jewish Healthcare Foundation
◦ “nothing more we can do”
have you heard others say this before?
What may patients hear and think?
What can we do?
© 2015 Jewish Healthcare Foundation
What We Learned in Closure
Community Conversations
Systems defaults are set wrong
Doctors avoid communicating
realistic prognosis
Advance plans are made too late,
if at all
Plans are not communicated effectively, nor
Referrals for palliative care and hospice are
too late
Medicine focuses on cure vs. care
© 2015 Jewish Healthcare Foundation
What Resulted from our First
Closure Community Conversations
Actions Plans that focused on:
 Training (Communications, Prognostication,
 Planning (Legal, Medical, Psychological)
 Systems Change: (Policy, Payment, Defaults)
 Attitudes (Personal, Professional,
© 2015 Jewish Healthcare Foundation
© 2015 Jewish Healthcare Foundation
In 2011:
WQED Documentary “The Last Chapter”
premiered June 30, 2011
 Followed up with a Viewer’s Resource
guide and DVD
 Accompanied by staffed Town Hall meetings
In 2012:
The Last Chapter was selected by PBS for
national distribution in over 200 markets
We introduced a website and guides to help
others hold successful Closure series
© 2015 Jewish Healthcare Foundation
Choosing A Convener
Determine Invitees
Preparing Content
◦ Speakers (from the group)
◦ Sample agendas
◦ Readings
Determining Site(s)
Starting the Conversation
Developing Action Coalition and Plan
© 2015 Jewish Healthcare Foundation
© 2015 Jewish Healthcare Foundation
© 2010 Jewish Healthcare Foundation
© 2015 Jewish Healthcare Foundation
© 2015 Jewish Healthcare Foundation
[email protected]
judith/[email protected]
© 2015 Jewish Healthcare Foundation
Physician Orders for Life-Sustaining Treatment and Emergency
Medicine: Ethical Considerations, Legal Issues,
and Emerging Trends
John E. Jesus, MD*; Joel M. Geiderman, MD; Arvind Venkat, MD; Walter E. Limehouse Jr, MD, MA; Arthur R. Derse, MD, JD;
Gregory L. Larkin, MD, MA; Charles W. Henrichs III, MD; on behalf of the ACEP Ethics Committee
*Corresponding Author. E-mail: [email protected], Twitter: @JohnJesus621.
Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing
in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and
frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/
do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the
quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the
interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical
considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.
[Ann Emerg Med. 2014;64:140-144.]
A podcast for this article is available at www.annemergmed.com.
0196-0644/$-see front matter
Copyright © 2014 by the American College of Emergency Physicians.
Emergency physicians frequently care for dying patients and
often make time-sensitive decisions without adequate medical
history and knowledge of the patient’s end-of-life care preferences.
The patient may not be able to communicate with the physician, and
accompanying documents, such as an advance directive or do-notresuscitate (DNR)/do-not-intubate (DNI) document, commonly
do not adequately guide the physician in making decisions about
critical interventions.1,2 The complex medical conditions of an aging
population and technologic advances that provide an increasing
number of options for intervention compound the problems related
to end-of-life care in the emergency department (ED). The
Physician Orders for Life-Sustaining Treatment (POLST) was
developed to provide a means for patients to inform caregivers about
specific treatment preferences, with clarity and sufficient nuance,
before death is imminent. Although POLST documents may also be
referred to as physician orders for scope of treatment, medical orders
for scope of treatment, and medical orders for life-sustaining
treatment, they all share the same core elements with similar form
design.3 This article will review the evolution of the POLST form,
address relevant ethical issue considerations, and discuss
implementation of POLST and future developments as they apply
to emergency medicine.
POLST emerged as a response to a number of trends in
emergency medicine. Cardiopulmonary resuscitation (CPR),
140 Annals of Emergency Medicine
originally developed for patients with potentially reversible
cardiac arrest, began to be used in almost all cardiopulmonary
arrests, in part because it was presumed that reasonable
individuals in a similar situation would choose to receive
lifesaving interventions.4 Because of this widespread practice,
DNR orders were developed for people with advanced chronic
medical illnesses for whom the use of resuscitation was unlikely
to substantially alter life expectancy or would not be appropriate
because of the patient’s or surrogate’s wish to forgo life-sustaining
treatment.5 Typically, DNR orders applied during the hospital
stay but did not follow the patient on discharge.6
As emergency medical services developed protocols for
treating patients in the out-of-hospital setting, it was recognized
that DNR orders could identify patients for whom resuscitation
should be withheld during out-of-hospital treatment and
transport. Out-of-hospital or “community” DNR orders (also
referred to as “standing” DNR orders) were developed and
enacted legislatively in many states and had authority as valid
expressions of patient end-of-life treatment preferences in the
out-of-hospital, ED, and inpatient settings.7
The Center for Ethics in Health Care at Oregon Health
Sciences University in 1991 convened a task force to address
standardized portable medical orders for patients with
progressive, chronic illnesses in regard to life-sustaining medical
treatment, including resuscitation, intubation, antibiotics, and
artificial nutrition and hydration. In 1993, the university adopted
the name Physician Orders for Life-Sustaining Treatment and
acronym POLST, and early studies showed their effectiveness
in increasing care delivered in accordance with patient wishes.8,9
Volume 64, no. 2 : August 2014
Jesus et al
In 2009, the statewide Oregon POLST registry was devised to
allow electronic access to a central registry rather than relying on
a paper form or health care institution medical record.10 The
POLST program has continued to help clinicians honor patient
wishes, becoming a valuable adjunct to advance directives.11,12
In addition to the 16 states that have fully endorsed POLST
programs by the end of 2013, another 27 have programs in
development, leaving just 7 without a POLST program in some
stage of development.13 For a list of states and respective POLST
forms and other related resources, visit: http://www.polst.org/
Commonly encountered models for advanced care planning
in the ED are advance directives, standing DNR (sometimes
called do not attempt resuscitation rather than DNR), and DNI
orders. Although each was developed to communicate patient
preferences for end-of-life care, over time advance directives and
DNR/DNI orders have been criticized for falling short of that
purpose.1,2,14,15 POLST forms, on the other hand, purport to
make up for the shortcomings of DNR/DNI and advance
directive documents.
Although the original aim of advance directives was to
improve clarity, allowing room for detail and flexibility as
necessary to give patients control of end-of-life treatment, 30
years of efforts to promote their use have failed, achieving only an
estimated prevalence of 18% of the adult population in the
United States.15 In a single-center survey study of Canadian ED
patients, only 5.6% of the 19.3% of patients who reported
having an advance directive brought it with them to the hospital;
as a result, emergency physicians do not often have access to this
information when it is most needed.16,17 Advance directives also
mistakenly assume that patient preferences are stable over time
and across all clinical scenarios.1,18 In reality, however, the
reversibility of a patient’s illness and the probability of his or
her survival heavily influence end-of-life treatment preferences.19
In addition, patients infrequently expend the emotional energy
required for advance directive planning; do not understand the
unpredictable, uncertain, and complex nature of critical illness;
and do not acknowledge or anticipate that advanced directives
and proxies can and sometimes do complicate critical care.1
Finally, despite the fact that more than a quarter of elderly
US residents require surrogate decisionmaking, their surrogates
frequently make inaccurate substituted judgments.14,20
The prevalence of standing DNR/DNI orders for ED patients
is less clear. Most frequently used for patients with a clear
terminal condition, these standing orders require a physician’s
signature on a state-approved form.21 Given the role selfdetermination plays in our basic understanding of ethically
appropriate medical care, it is crucial that any document used
to convey patient preference for life-sustaining measures be
as accurate as possible. DNR/DNI orders do not include
Volume 64, no. 2 : August 2014
POLST in Emergency Medicine
considerations of preferences based on context, survivability,
or other considerations not included in the document. Despite
the specificity implied by the title of the orders themselves,
clinicians frequently more broadly interpret DNR/DNI orders
beyond precluding CPR and intubation. Previous studies have
demonstrated that if they have a DNR order, patients in acute
heart failure are less likely to be treated according to quality
assurance measures, nursing home patients are less likely to be
hospitalized when receiving a diagnosis of pneumonia, and
patients with cardiac disease admitted for acute coronary
syndrome are less aggressively treated and more likely to die.22-24
Even decisions concerning patient disposition are influenced by a
patient’s DNR status, with lower rates of admission to an ICU
regardless of a patient’s age, Acute Physiology and Chronic
Health Evaluation II score, or functional status.25 Given that
patients with DNR/DNI orders frequently desire aggressive
treatment for acute conditions short of CPR, advance directives
with greater delineation of patient end-of-life preferences were
proposed to enhance communication of those wishes.2,26
POLST documents address many of the previously
discussed criticisms of DNR/DNI and advance directives (see an
example form in Appendix E1, available online at http://www.
annemergmed.com). Their use is intended for seriously ill or
frail patients with life-limiting advanced illness, patients who
have the threat of losing their decisionmaking capacity, and
anyone with strong treatment preferences.27 POLST forms
break end-of-life care interventions into categories of care
(CPR, medical interventions including intubation, antibiotics,
and artificial hydration and nutrition) and present patients with 2
or 3 corresponding clear choices, ranging from comfort measures
only, to supportive noninvasive treatments, to full treatment.
The form also requires a description of patient goals. Whereas
DNR/DNI documents are too specific to guide clinicians outside
the avoidance of CPR and intubation and advance directives
are often too general to apply to specific medical encounters,
POLST documents serve as a middle ground, translating patient
goals and values into medical orders that are easily understood
and specific enough to apply to most medical encounters.
Early evidence of POLST usage suggests important
improvements over traditional DNR orders in the
communication and implementation of patient end-of-life care
preferences. Hickman et al28,29 studied 146 nursing facilities in
Oregon with 356 residents aged 65 years and older and found
that most facilities use POLST to convert patient preference to
medical order. They also found that a majority of residents with
DNR orders as part of their POLST forms had a preference
for treatment in at least 1 other category, whereas nearly half
of patients with orders to resuscitate had orders to limit treatment
in at least 1 other category. These findings strongly suggest
that DNR status alone does not predict patient preferences for
the level of aggressiveness and that POLST forms are useful in
Annals of Emergency Medicine 141
POLST in Emergency Medicine
capturing those preferences.30 These early studies suggest that the
use of POLST carries significant advantages in accurately
communicating preferences for life-sustaining therapies, beyond
CPR and intubation, where DNR orders and advance directive
have fallen short.
In addition to the focus on self-determination, the use of
POLST may help clinicians improve the quality of care
administered. In its 2006 consensus report, the National Quality
Forum listed the use of POLST as a “preferred practice,”
recognizing the community collaboration and cooperation
involved in a state’s adoption of the POLST paradigm as an
effective method of promoting advance care planning.31
Advanced care planning, in turn, can help patients and their
families prepare for death, achieve peace of mind, and create
higher levels of overall patient satisfaction.32 Furthermore, a
multicenter study examining the consistency between treatments
provided to nursing home residents and their POLST documents
reported that 94% of the interventions provided were consistent
with their POLST orders.29 Personnel in hospice care settings
have also noted POLST to be useful, helpful, and reliable.29
Given the benefits of advance care planning, the favorable
opinions of health care personnel, and the consistency of the care
administered to patients with POLST orders, a cogent argument
can be made that the POLST paradigm has the potential to
improve the quality of end-of-life care, in addition to more
accurately describing patient preferences.
There are several ethical considerations in regard to the use
of documents addressing end-of-life care preferences, including
those expressed in the POLST form. Although documents such as
DNR/DNI and POLST are valuable in communicating patient
preferences, clinicians should confirm with patients who have
decisionmaking capacity that such documents continue to express
the patients’ wishes, giving patients the opportunity to voice
any changes in treatment preferences. If a patient with intact
decisionmaking capacity elects a course of treatment that seems to
change his or her documented preferences, it is incumbent on the
emergency physician to discuss such changes with the patient to
ensure clarity in goals of acute therapy, including relevant family
members and other appropriate providers whenever possible. A
patient with intact decisionmaking capacity has the authority to
override previous advanced planning documents. In the absence
of patient decisionmaking capacity, however, the emergency
physician should rely on a valid POLST document as the best
proxy for patients’ goals of care and treatment preferences
There are a number of potential legal barriers to the
development of a state POLST program, including already
existing laws governing living wills, durable powers of attorney
142 Annals of Emergency Medicine
Jesus et al
Figure. Common challenges in the use of POLST forms.
for health care, default surrogate provisions, guardianship law,
and out-of-hospital DNR protocols.3 In addition, the
appropriate state authority must recognize the orders as valid for
use by emergency medical services. Nursing homes, hospices,
emergency facilities, and hospitals must also recognize its validity,
which may require modifying bylaws about clinician
credentialing. Implementing POLST in EDs is just one step
within a community or statewide initiative to develop and adopt
the physician order form for local use.12 Education of health
care professionals to use the forms with patients when discussing
end-of-life care will also represent a challenge.33,34 There is,
however, a library of resources to assist states wishing to develop
a POLST program, offered on the http://www.polst.org
Web site, that includes training videos, brochures, providers and
consumer guides, implementation checklists, and sample forms.
In the ideal application of the POLST paradigm, the form is
appropriately filled out and signed after an informed discussion
with a patient’s physician, always accompanies the patient, and
has the authority to represent the patient’s end-of-life care
preferences in all clinical settings. This may avoid unnecessary or
unwanted transfers to the ED. Despite what might happen under
ideal circumstances, however, there are many challenges that may
occur while trying to manage a patient with a POLST form.
These include caring for a patient whose POLST form is not
available or was not transported with the patient, insufficient
completion of the form or lack of authorizing provider signature,
surrogate decisionmakers who report changes to a patient’s
end-of-life care preferences that contradict the POLST form,
and others situations (Figure). Solid understanding about the use
of the form, along with urgent administrative, legal, or ethical
consultation, may be needed.
Although most states have either an established or developing
POLST program, many have not yet provided explicit statutory
Volume 64, no. 2 : August 2014
Jesus et al
protection of physicians seeking to honor patient wishes through
a POLST form (as is frequently provided in the setting of
DNR orders and advance directives). As a result, many physicians
are concerned about the legal liability involved in using the
forms. Even in those states without explicit statutory protection,
however, physicians are protected by common law by compliance
with generally accepted standards of practice in their area.35
Furthermore, the federal government takes a strong position
on the hospital’s obligation to honor patient decisions concerning
their care.36 Finally, we are not aware of a single suit brought
against a physician who followed the wishes of a patient as
documented by a POLST form in the more than 10 years
of its use.
Even given its success in capturing patient preferences where
DNR/DNI and advance directives have fallen short, however,
recently published literature points to a need for further study and
refinement. In a study of 31,294 POLST forms examining the
various combinations of orders that may be chosen, Schmidt
et al37 revealed small populations of patients who choose order
sets that are not medically feasible or logically consistent (eg,
attempt resuscitation and comfort measures only) or that might
require more interpretation than time might allow during an
emergency (eg, attempt resuscitation and limited interventions).
More broadly interpreted, POLST is a relatively new method of
communicating patient preferences for end-of-life care, and there
is still much to investigate in regard to the outcomes on capturing
patient preferences and on the quality of end-of-life care delivered.
The penetration and adoption of POLST is increasing
rapidly.38-40 In a time in which technology and consumerism
drive change, POLST is likely to gain considerable traction as
cloud-based data storage and transfer become increasingly secure
and accessible. Cloud-based POLST registries are the natural
progression of mature programs in states such as Oregon and are
already proving to be effective tools for making legally executed
POLST documents available to emergency personnel and other
health professionals.41,42 A more centralized, federal system
allowing access to information such as that offered by the
Department of Veterans Affairs’ Veterans Health Administration
may allow the management of large POLST registries.43 There
are still legitimate challenges with cloud-based POLST registries,
including portability, legality, compliance, access management,
data loss prevention, infrastructure expansion, and data lifecycle
management.44 Although privacy concerns and the legal standing
of such digitized POLST documents may be challenged, there is
good reason to expect POLST documents to be found anywhere
digitized information may be stored.
As we seek to preserve the dignity of patients in the final
moments of their lives, the need for an ability to communicate
patient end-of-life treatment preferences grows more desirable
and compelling. The POLST paradigm has potential advantages in
accuracy and penetration over advance directive and DNR/DNI
Volume 64, no. 2 : August 2014
POLST in Emergency Medicine
documents and may positively contribute to the quality
of end-of-life care administered. Although the development of
POLST programs can be arduous and the use of the document
challenging, evidence of its effectiveness, an aging population,
and technological advances promise to push the paradigm
forward. Working at the front lines of medicine, emergency
physicians are likely to see POLST documents more frequently
and should learn to recognize, interpret, and implement them
Supervising editor: Timothy F. Platts-Mills, MD, MSc
Author affiliations: From the Christiana Care Health Center,
Newark, DE (Jesus); the Cedars-Sinai Medical Center, Los Angeles,
CA (Geiderman); the Allegheny Health Network, Pittsburgh, PA
(Venkat); the Medical University of South Carolina, Charleston, SC
(Limehouse); the Medical College of Wisconsin, Milwaukee, WI
(Derse); the University of Auckland, Auckland, New Zealand
(Larkin); Pardee UNC Health Care, Hendersonville, North Carolina
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article as per ICMJE conflict
of interest guidelines (see www.icmje.org). The authors have stated
that no such relationships exist.
Publication dates: Received for publication November 9, 2013.
Revisions received January 18, 2014, and March 11, 2014.
Accepted for publication March 17, 2014. Available online April 16,
1. Perkins HS. Controlling death: the false promise of advance directives.
Ann Intern Med. 2007;147:51-57.
2. Jesus JE, Allen MB, Michael GE, et al. Preferences for resuscitation and
intubation among patients with do-not-resuscitate/do-not-intubate
orders. Mayo Clin Proc Mayo Clin. 2013;88:658-665.
3. Hickman SE, Sabatino CP, Moss AH, et al. The POLST (Physician Orders
for Life-Sustaining Treatment) paradigm to improve end-of-life care:
potential state legal barriers to implementation. J Law Med Ethics
J Am Soc Law Med Ethics. 2008;36:4, 119-140.
4. Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl
J Med. 1976;295:364-366.
5. Blackhall LJ. Must we always use CPR? N Engl J Med.
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Approach to Ethical Decisions in Clinical Medicine. New York, NY:
McGraw-Hill Medical; 2010.
7. Iserson KV, Rouse F. Prehospital DNR orders. Hastings Cent Rep.
1989;19:17; discussion 17-19.
8. Dunn PM, Schmidt TA, Carley MM, et al. A method to communicate
patient preferences about medically indicated life-sustaining
treatment in the out-of-hospital setting. J Am Geriatr Soc.
9. Schmidt TA, Hickman SE, Tolle SW, et al. The Physician Orders for
Life-Sustaining Treatment program: Oregon emergency medical
technicians’ practical experiences and attitudes. J Am Geriatr Soc.
10. Oregon Health & Science University. POLST registry launched
[Internet]. [Cited November 9, 2013.] Available at: http://www.ohsu.
Annals of Emergency Medicine 143
Jesus et al
POLST in Emergency Medicine
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Fromme EK, Zive D, Schmidt TA, et al. POLST registry do-notresuscitate orders and other patient treatment preferences. JAMA.
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state POLST programs [Internet]. AARP Public Policy Institute; 2011 [cited
November 9, 2013]. Available at: http://assets.aarp.org/rgcenter/ppi/
cons-prot/POLST-Report-04-11.pdf. Accessed April 8, 2014.
POLST programs by state [Internet]. POLST programs by state. 2013.
Available at: http://www.polst.org/programs-in-your-state/. Accessed
April 8, 2014.
Silveira MJ, DiPiero A, Gerrity MS, et al. Patients’ knowledge of options
at the end of life: ignorance in the face of death. JAMA.
Fagerlin A, Schneider CE. Enough. The failure of the living will.
Hastings Cent Rep. 2004;34:30-42.
Gina K, Gill G, Fukushima E, et al. Prevalence of advance directives
among elderly patients attending an urban Canadian emergency
department. CJEM. 2012;14:90-96.
Taylor DM, Ugoni AM, Cameron PA, et al. Advance directives and
emergency department patients: ownership rates and perceptions of
use. Intern Med J. 2003;33:586-592.
Sehgal A, Galbraith A, Chesney M, et al. How strictly do dialysis patients
want their advance directives followed? JAMA. 1992;267:59-63.
Fried TR, Bradley EH, Towle VR, et al. Understanding the treatment
preferences of seriously ill patients. N Engl J Med.
Sulmasy DP, Terry PB, Weisman CS, et al. The accuracy of substituted
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Did you know?
Continuing Medical Education for Annals articles is available at http://www.acep.org/ACEPeCME/.
144 Annals of Emergency Medicine
Volume 64, no. 2 : August 2014
Iowa POLST Legislative Summary
Stephanie Anderson, MSN, RN, CHPN
January 19, 2015
In October 2006, UnityPoint Health - St. Luke’s Hospital (Stephanie Anderson) and Mercy Medical Center
(Christine Harlander) formed a partnership to improve communication for chronic and terminally ill
patients who want their healthcare decisions known and honored. This partnership resulted in a POLST
pilot project and ultimate statewide implementation called IPOST (Iowa Physician Orders for Scope of
Treatment). Initially, a local focus group was convened to move the project forward. It was determined
by the focus group that legislative action would be required.
The project was initially presented to the Iowa Affordable Healthcare Commission in Bettendorf on
September 27, 2007. All healthcare commission members were supportive of the project; no opposition
was voiced. An Iowa House Representative asserted that if both organizations were working on this
project together, it must be important for the community. The collaborative effort between the two
competing organizations was a key component throughout this project to move it forward.
Identification of stakeholders, connecting and building relationships while gaining support for the
project preceded legislative action. Legislative language regarding an initial pilot proposal was written. It
was presented to the Iowa Senate subcommittee charged with reviewing the Affordable Healthcare
Commission’s report. After discussion and extensive vetting of the proposed pilot legislation, Iowa
Legislative House File #2539, the Health Care Reform Bill; Patient Autonomy in Health Care Decisions
Pilot Project was passed and signed by the Governor on May 13, 2008. This bill established the IPOST
pilot for Linn County, Iowa, under the Iowa Department of Public Health (IDPH) for two years (July 1,
2008 and ending June 30, 2010) with local decisions to be made by a community coalition. The state
legislature did not appropriate any funds to the project. To our knowledge, the IPOST pilot project was
the first such project in the nation to be authorized legislatively.
The legislation also called for a report to the Governor and the Iowa Legislature in January 2010. The
legislation directed IDPH to convene an advisory council to hear the results of the local pilot and to make
recommendations to the Governor and Iowa Legislature. The Iowa Patient Autonomy State Advisory
Council which was made up of the legislatively identified stakeholder groups and organizations as well
as representatives of the local pilot projects created recommendations for the Legislative Assembly.
Subsequently, the pilot was extended to include a contiguous rural county (Jones County) with a final
report due January 2012.
Per recommendations of the State Advisory Council, then the Legislative Assembly, new legislation was
drafted which passed in the Iowa House of Representatives and finally in the Iowa Senate (unanimously)
on February 22, 2012. The Iowa Governor signed the bill into law March 7, 2012 effective July 1, 2012.
This brief summary of the significant legislative events does not do justice to the amount of time and
human resources required behind the scenes resulting in success. The following table provides a brief
list of successes and challenges to this legislative process and by no means is all inclusive.
Iowa POLST Legislative Summary
Stephanie Anderson, MSN, RN, CHPN
January 19, 2015
Legislative Successes
Engagement of key legislators to champion and
support legislation
Created standardized IPOST messages and
strategies developed to acknowledge and address
any concerns (talking points).
Connecting and building relationships.
Engagement of key stakeholders early in process
(e.g., medical provider groups, legal community,
long-term care ombudsman, Iowa Catholic
Conference, AARP, bioethics, right to life groups,
and identified “doubters”). These groups reviewed
bill but also relied upon their national umbrella
organizations for input
Hospice and Palliative Care Association of Iowa
named IPOST as top legislative priority and
assigned lobbyist (whom also participated in
drafting legislation)
Iowa Bureau of EMS actively supported legislation
routinely meeting with key legislators
UnityPoint Health corporate lobbyist engaged
Variety of educational strategies (e.g., letters to
legislators, state organizations’ education agendas,
state and local conference presentations)
Engagement through variety of strategies (e.g.,
patient testimonials, letters from patients to
legislators and other key stakeholders)
Significant time volunteered by four local pilot
leaders to support legislative action as content
experts (e.g., being present at all Senate
subcommittee hearings, addressing concerns and
questions from legislators, key stakeholders and
the public/media timely, provided feedback on
legislative language being written, as content
Intentional education to healthcare organizations
(e.g., long term care, emergency departments,
home care, hospice, hospitals) and all associated
state organizations
Intentional to include in legislation:
 signatures by ARNP and PA due to 88 of 99
rural counties in Iowa and lack ready access to
 physician immunity
 must follow National POLST paradigm
Legislative Challenges
Did not create written strategic plan for legislative
Lack of any funding to support legislative action
Resistance due to lack of information and time to
collaborate regarding IPOST prior to major
legislative funnel from the Iowa Medical Society
and ISBA Probate Section Members
Did not engage legal community early which
resulted in many meetings and questions from
estate attorneys however did not result in barrier
but learned lesson
Lack of understanding regarding POLST as a
process and not just a form/checklist/AD
Iowa POLST Legislative Summary
Stephanie Anderson, MSN, RN, CHPN
January 19, 2015
Early decision to create new legislation; avoiding
attempts to change current Advance Directive or
Out-of-hospital DNR (OOH-DNR) legislation
Determined key stakeholders to engage based on
past experience with resistance to OOH-DNR
Awareness of always connecting IPOST with key
stakeholders’ mission, vision and strategic plan
Support from National POLST Paradigm;
instrumental in assisting with questions.
Examples of Questions Received during Iowa Legislative Process
Is this legislation modeled on legislation now in place and proven to be workable and beneficial?
How is a POST different than a physician’s order entered now into the chart of a hospital or
nursing facility? Is this just more paperwork?
Why is this legislation needed? What problems will this legislation remedy? Is legislation the
best way to address identified problems? What kind of fact-finding is there to support a need for
this legislation and its likely benefits?
What other organizations say that this is a good process/What are its down sides?
How is this legislation different from Iowa’s durable power of attorney statute? Must an agent
named under the DPOA be bound by the patient’s POST even if circumstances have changed
and it is in the best interest of the patient to act contrary to the patient’s POST?
In what ways might patient and/or their families and/or their physicians feel hampered by this
legislation and documents executed under its authority?
Could facilities require the execution of a POST as a condition of admission?
Could physicians, as a condition of an ongoing physician-patient relationship with a person in a
health facility or hospital, require patients to execute a POST?
How can a patient anticipate today all care situations that decisions may be required for?
Will a patient executing such a document truly be giving informed consent? (I fear this is a very
real legal impediment to this proposed legislation given the broad scope of a POST. By contrast,
Iowa’s living will statute is narrow in scope and definitionally supported so that when a patient
executes a living will declaration, the patient is informed as to the conditions that would need to
be in place before the declaration would be effectuated?
Suppose circumstances change for a patient but the family/physician can do nothing different
because of the directions in the POST?
Could the immunity protections of this statute too broad given the broad scope of a POST as
provided for in this legislation and its definitions?
Are there medical ethical impediments associated with various implementation scenarios under
this statute?
Iowa POLST Legislative Summary
Stephanie Anderson, MSN, RN, CHPN
January 19, 2015
Legislative resource information
Iowa legislative language: Iowa Code, Chapter 144D;
National POLST Paradigm at http://www.polst.org/educational-resources/legal-and-policy/. Legal
Resources including potential state legal barriers to implementations, regulatory/legislative comparison
of state programs and POLST legislative guide (2014)
Sabatino, C., & Karp, N. (2011). Improving Advanced Illness Care: The Evolution of State POLST
Programs. AARP Public Policy Research Report. Retrieved from: http://www.aarp.org/health/doctorshospitals/info-04-2011/polst-04-11.html
A Hospital Based POLST Pilot
JFK Medical Center
Atlantis, Florida
• Founded in 1966
• 460 beds
• Owned by HCA
• Affiliation with University
of Miami Internal
Medicine Residency since
First Steps
• Physician Champion
• Letter to CEO/CMO
• Ethics Committee
Second Steps
• Medical Executive
• Edit hospital’s current
DNR Policy
• Create a new POLST
Third Steps
• Approve Order Form
• Work out the “Kinks”
• Distribute Hospital Wide
“Those affected”
“Those who
“Those Who Order” - Physicians
• Intensive care units
• Hospitalists
• Primary care providers
• Select specialties
“Those Who Implement”
• Nursing Leadership
• Emergency Department
• Hospice units
• EMS Personnel
“Those Who Are Affected”
• Hospital Website
• Local newspaper/Radio
• Patient advocacy groups
• At the bedside when
completing the form
Hospital Based Approach
Ideas for Data Collection
• Pre-Post Studies
• % of Hospitalized Patients
With a Written Advance
Directive at the time of
• Adherence to wishes
• Patient satisfaction
• Practitioner satisfaction
2015 NPPTF Annual Meeting
Rick Bassett, MSN, RN, APRN,
Adult Critical Care CNS
Healthcare Team
February 6, 2015
• Identifying and understanding your role in engaging
• Recognize fundamental principles in finding and engaging
• Provide summary of key issues/barrier in engaging the
healthcare team
Your Role
• Identify opportunity/define the need
• Understand current programmatic elements
• Define the future state
• Create action plan to engage champions/leaders
• Executing the plan
• Understanding ways to maintain engagement
Identifying the Opportunity
• Understanding your current programmatic elements
• Who do you already have engaged?
• Identify gaps in expertise/content
• Consider the following:
• Discipline
• Specialty
• Clinical
• Administrative
• Connectivity
• Acute Care
• Clinic/Outpatient
• Home Care/Hospice
• Legal
• Insurance
• Other non-profit entities
Identifying the Opportunity
• Understanding your current programmatic elements
• Does your cause/organization/coalition have a mission and
• Ex:
• Vision Improved care, conditions, and access to quality
end-of-life care.
• Mission Work cooperatively with other organizations to
provide knowledge, tools, and mechanisms to promote
compassionate end-of-life care, including hospice and
palliative care
• What current activities are you involved in?
• What about those activities will attract leaders/champions?
• What is a leader?
• What is a champion?
Identifying the Opportunity
• The Future State
• Key to demonstrating a need for engagement and ongoing
commitment to the larger priorties
• Provides structure for development of short term goals
• Crosswalk details of future state with strategic goals for the
organizations which your leaders and champions represent
Engagement Tactics
• Understanding the evidence
• Read up on topic, become knowledgeable and enthusiastic so you can motivate
• Defining the opportunity
• What are you already doing to address opportunities?
• What does the opportunity look like in your community?
• Query potential leaders/champions re: opportunities
• Evaluate needs and determine objective goals
• Identify knowledge/process barriers
• Consider the value of data
• Making your case
• Consider all stakeholders (not just group members but all stakeholders)
• Communicate opportunities for improvement and goals
• Getting the right people to the table
• Process leaders- Administrators, Community Leaders, Attorneys
• Multidisciplinary team members
• Meeting and training time to develop and implement the program elements
• Understand your resource needs
Engagement Tactics
• Consider where to best operationalize the talents of the leaders/champions
• Work groups
• A group of individuals that work together to achieve a stated objective
• 3-5 for smaller tasks, sometimes up to 7-8 for larger tasks
• Oversight groups
• provides management for the different work groups
• Helps to assure goals/tasks are accomplished within the specified timeframe
• Boards
• Provides for the executive functions of the cause/entity/coalition
• Defines the mission/vision
• Ultimately responsible for assuring adequate and ongoing resources to fuel the
• Know their organization or interests
• Draw a parallel with what your organization is doing
Engagement Tactics
• Triple Aim
• Improved care
• Reduced cost
• Better health
• Accountable Care Organizations
• Healthcare organizations and providers create coordinated network
• Meets needs of all consumers in the service area (could be local, regional,
• The goal of coordinated care is to ensure that patients, especially the
chronically ill, get the right care at the right time, while avoiding
unnecessary duplication of services and preventing medical errors.
Engagement Tactics
Improves patient care:
Effective advance care planning and use of the POLST can
better ensure that patients receive medical management
that matches their identified goals.
Personalized medical management leads to
• The highest level of function possible,
• Timely symptom management, and
• Timely use of treatment along with palliative and hospice
care with no change in length of life
• While avoiding unwanted treatment that could likely lead
to increased discomfort and decreased quality of life
Engagement Tactics
Improves population health:
Patients and families are more satisfied with their care,
Planning lowers moral distress, and
Increased communication leads to healthier bereavement
after the death of the patient
Promotes better prepared surrogate decision makers
Engagement Tactics
Reduced cost of care
Helps to focus treatment based on patient/client wishes
Reduces unnecessary/unwanted tests that lack value
Reduces use of high cost/high tech service where they
don’t help to achieve treatment goals
Keeping Leaders/Champions
• Maintaining the engagement
• Assure you have a well defined timeline for each intiative
• Set interim (short-term) goals
• Quick wins
• Steady progress
• Have a well defined structure for accomplishing the work
• Meeting space
• Group expectations of each individual member
• Maintain a reasonable workload expectation
• Provide for leadership opportunities
• Succession planning
• Deeper engagement
• Workload
• Focused meetings
• Always have an agenda (send prior to the meeting)
• Engage leaders/champions in building the agendas
• Assure out-of-meeting work is reasonable and well distributed
Questions are guaranteed in life.
Answers aren’t
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