This document provides guidance for handling challenging questions during interviews

SPEAKER TRAINING TOOL FOR POLST PRESENTERS
This document provides guidance for handling challenging questions during interviews
and presentations about POLST. It provides examples of challenging questions and
suggested talking points for how to respond.
Please note: this document is for internal use only. The Frequently Asked Questions
(FAQ) documents on the www.caPOLST.org web site are for external use, and can be
given to providers, patients, and families.
What is POLST?
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POLST is a physician order that gives patients more control over their end-of-life
care by specifying the types of medical treatment they want to receive.
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POLST:
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Encourages communication between providers and patients
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Enables patients to make more informed decisions, and
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Clearly communicates these decisions to providers.
As a result, POLST can:
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Prevent unwanted or medically ineffective treatment
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Reduce patient and family suffering, and
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Help ensure that patient wishes are honored.
In technical terms, POLST:
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Is a standardized form for the whole state.
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Is easily distinguished by its bright pink color
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Is recognized throughout the medical system
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Transfers with the patient from one care setting to another.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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How does POLST work?
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POLST starts with a conversation between the patient and a health care provider—
either the patient’s physician or another member of their health care team.
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The provider talks to the patient to understand the patient’s goals of care and
how those goals translate into treatment choices on the POLST form.
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The provider offers information about the patient’s medical condition, the
expected course of the patient’s illness, and treatment options that are available
so the patient can make an informed decision.
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If the patient decides to complete a POLST, the provider fills it out to document
the patient’s treatment preferences.
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In some cases, a POLST form may not be completed when it is initially
discussed, but during follow up conversations.
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To become valid and actionable, the POLST form must be signed by both the
patient’s physician, and the patient or their decisionmaker.
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Once signed, the POLST becomes an actionable medical order that travels with
the patient, even as the patient moves between care settings.
Why do we need POLST? Why is POLST necessary?
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Patient wishes often are not known.
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Even if a patient has an Advance Health Care Directive, it may not be available
when it is needed, and the patient’s wishes may not be clearly defined in the AHCD.
There is no standard AHCD form.
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POLST outlines actionable medical orders that are clearly understood and
followed by health care professionals.
Are patients required to complete a POLST? Can patients be required to have a
POLST form in certain care settings?
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POLST is completely voluntary.
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Though POLST is a helpful document for health care providers, a patient should
not be required to complete a POLST form. It is their choice.
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While the use of POLST is not mandated, honoring a patient’s POLST is mandatory.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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What happens if the treating physician disagrees with the orders in the POLST?
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The purpose of POLST is to ensure that patient wishes are honored.
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If a physician has questions or concerns about a patient’s POLST form, he/she
should raise them with the patient or the patient’s decisionmaker.
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If there are new facts about the patient’s expressed wishes that would give the
physician reason to think the patient’s wishes have changed, or if there has been
a change in the patient’s condition, the physician can reassess the decisions on
the POLST form.
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There are two very rare exceptions where a physician may change the POLST:
o If the POLST calls for treatment that is contrary to generally accepted
medical standards, or
o If the POLST calls for treatment that is medically ineffective.
− For example, if the POLST calls for treatment that may have been
appropriate when the form was first completed, but changes in the
patient’s condition make those same treatments futile at this point in
the patient’s course of illness.
− A clinical example would be a POLST form indicating CPR for a person
who has metastatic cancer with renal failure. [NOTE: would like to get
one or two clinical examples from one of our task force members.]
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Treating physicians may wish to consult their facility’s ethics committee for
additional guidance.
Who can speak for a patient? What if there is no family or decisionmaker?
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The legally recognized health care decisionmaker includes anyone recognized
under California law, including:
o The person named in the advance directive, whether it is a verbal advance
directive, which is time limited, or a written advance directive.
o The parent of a minor, a guardian, or a conservator.
o If none of those people exist, then health care providers may turn to the
“closest available relative” to make decisions. This term was established
in case law and the court did not define it.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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In the case of SNF residents without known relatives, the multi-disciplinary Eppel
committee is authorized to consent only to affirmative treatment on behalf of the
patient – they may not consent to withholding or withdrawing treatment. So with
POLST, they may only select CPR, Full Treatment, and Long-Term Tube
Feeding.
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Many acute care facilities have policies on decisionmaking for the unrepresented
patient. Check with your individual facility.
What happens if a family member wants to change the order at a point when the
patient can no longer speak for themselves?
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One of the primary goals of POLST is to ensure that patients have more control
over their medical treatment, even after they cannot speak for themselves.
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If the patient lacks decisionmaking capacity, his or her decisionmaker may
request a change to the POLST form if there has been a change in the patient’s
condition or there is new information about the patient’s wishes. The
decisionmaker consults with the physician to determine what is in the best
interest of the patient based on the previously stated wishes and the new
information or change in condition.
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If there is no evidence to indicate that the POLST does not represent the
patient’s wishes, and there are no changes in the patient’s condition, it cannot be
changed by a family member.
What if a family member indicates that during a recent conversation with the
patient before he/she became incapacitated, the patient expressed different
wishes than what is documented on the POLST?
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One of the primary goals of POLST is to ensure that patients have more control
over their medical treatment, even after they cannot speak for themselves.
If a physician legitimately believes the patient’s wishes are different from what is
specified on the POLST, the form can be changed.
Situations like this can be very difficult, and there may be disagreements among
family members about the patient’s wishes. It can be helpful to remind family
members that a thoughtful conversation took place with the patient when the
POLST was completed. The treating physician may wish to consult a facility’s
ethics committee for additional guidance.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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What if a patient isn’t treated because of what it says on the POLST form, and it’s
later found out the doctor who signed the form didn’t have a conversation with
the patient?
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Health care providers can presume that all medical orders, including POLST,
were completed appropriately. If the POLST form looks legitimate, it should be
honored.
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California’s POLST law provides legal protections for health care providers that
follow the medical orders specified in a POLST.
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If questions arise in the course of treatment, a treating physician may wish to
contact the physician who signed the original form.
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If the treating physician concludes that the patient’s condition has changed since
the POLST form was completed, the physician can reassess the patient and
provide care in accordance with the patient’s wishes.
Does POLST encourage certain treatments or withholding them?
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POLST is more than a form – it involves a meaningful conversation between
patients, families, and their health care providers.
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POLST is about ensuring that patients have more control over their medical
treatment.
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Patients may choose the treatments they do want to receive, including CPR,
aggressive medical interventions, and long-term tube feeding, as well as
document those they do not want to receive.
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POLST is completely voluntary. No one is required to complete a POLST form.
How can providers counsel patients and families about the realistic effectiveness of
treatment options without making it seem like we are encouraging a particular
choice?
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Health care providers should talk about all the treatment options listed on the
POLST, including asking what that patient hopes to achieve by attempting
various medical interventions, and what brings quality and meaning to their life.
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It is important to be honest with patients and families about what treatments can
be expected to achieve for them.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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Some options are difficult to talk about, like feeding tubes and CPR.
o Cultural and religious views may play an important role for patients and
families.
o Many people have unrealistic expectations about what CPR can achieve,
particularly for someone with a serious illness or who is medically frail.
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Discussing the burdens and benefits of different treatments is essential for
helping patients make informed decisions, and helping families better understand
what is important to the patient.
Could you explain why CPR in Section A requires Full Treatment in Section B?
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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.
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It is not acceptable for a patient to request “Attempt CPR” and “Comfort
Measures Only”.
Could you explain why someone would choose DNR in Section A and Full
Treatment in Section B?
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This applies to the patient who has a pulse and/or who is breathing and wants
aggressive medical interventions, but who doesn’t want to be resuscitated if
found without a pulse or not breathing – in other words they are found dead.
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The severity of the patient’s illness and prognosis are important considerations to
discuss.
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It is important to address how long a patient would want treatment to continue. If
for example they were on a ventilator, would they want to be kept alive on the
ventilator for a prolonged period, or for a defined trial period to see if they
recovered.
In an emergency situation where a patient is being transported from a residence to a
hospital, who’s responsible for making sure that the POLST goes with the patient?
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In a private residence, the responding EMT should ask the patient or someone
else in the home if the patient has completed a POLST.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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EMTs may check the refrigerator, by the patient’s bed, or where the patient’s
medications are kept as this is where patients are counseled to keep their
POLST.
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The forms are printed on bright pink paper, so they’re usually easy to spot.
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In a skilled nursing facility or residential care facility, the POLST should be
included in the documentation that is sent along with the patient to the hospital.
How can we ensure that we get a patient’s POLST form back from the hospital?
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Some facilities make a copy of the patient’s POLST form when transferring them
to the hospital.
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When the patient returns to the facility with a POLST form, replace the form in the
resident’s chart with the new one to ensure you have the most recent version in
the chart.
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If the patient does not return with a POLST form, ask if a new POLST form was
created and get a copy from the hospital.
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If no new POLST form was created, check to make sure the POLST on file still
reflects the patient’s wishes after their hospitalization.
Is there a way to access POLST forms electronically (e.g., registry)?
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Currently in California, we do not have a POLST registry where completed
POLST forms are kept.
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POLST is still fairly new in California. We want to make sure we have enough
completed POLST forms to populate the registry.
o If a POLST registry is established too early, and EMS is not able to find
patients’ POLST forms, they will likely stop using it.
How is POLST being integrated into the electronic medical record?
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Each system is going about it in a way that works for them – there is no universal
way.
o Some are scanning the POLST form into the EMR and filing it under an
Advance Directive section.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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o Some have created an electronic version of the POLST form that is
completed electronically and stored in the electronic medical record.
However, because POLST is portable and stays with the patient, a hard
copy must be available for the patient to take with them.
o Some have created a flagging system to note the presence of a POLST
form immediately upon accessing the patient’s medical record.
Will POLST save money? How much? Is the main purpose of POLST to save
money?
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One of the primary goals of POLST is to ensure that patients have more control
over their medical treatment, even after they cannot speak for themselves.
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POLST is neutral in regard to cost. POLST allows patients to choose certain
treatments, as well as forgo treatment.
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While it’s possible that use of the POLST may save money by avoiding unwanted
or medically ineffective care, saving money is not the goal of POLST.
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We do not have any data about the financial impact of POLST at this time.
Questions from physicians
Having a conversation about POLST could take a long time. Can physicians bill
for that time?
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Possibly. If more than 50% of a clinical visit is spent on counseling the patient
about POLST, and POLST applies to managing one or more of the patient’s
conditions, then physicians may bill for that time using E&M codes. [99213 if
total time is 15 minutes; 99214 if total time is 25 minutes]
Are there financial incentives for physicians to complete POLST forms?
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Some medical groups may reimburse physicians for having advance care
planning conversations with patients, which may result in the completion of a
POLST form.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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Does POLST limit physicians’ flexibility to practice medicine using their
professional judgment?
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POLST is a helpful tool for documenting a patient’s wishes and guiding health
care professionals in proving the care that patients want, and avoiding those that
they do not want.
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When physicians respect what’s documented on a POLST form, they’re honoring
the patient’s wishes.
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Physicians and other health care providers play an integral role in the POLST
process—both by initiating the POLST conversation to help patients understand
their treatment options, and by following the orders outlined in the POLST to
ensure patients’ wishes are honored.
How are non-physicians qualified to complete the POLST form with patients? It
seems it should be done by physicians.
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POLST forms are physician orders, and physician involvement in the process is
vital.
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Nurses, social workers, and chaplains who are trained in having these kinds of
conversations may initiate POLST conversations, but the form does not become
an actionable medical order until it’s signed by a physician.
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When the physician signs the POLST form, he/she takes responsibility for what’s
written on the POLST form.
Questions from other providers:
With the amount of time involved in having a conversation about POLST, don’t
you think physicians will just fill them out without much thought?
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It’s up to each facility and practice to determine who leads a POLST conversation
with a patient.
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The conversation does take some thought and time, and other specially-trained
providers can play an important role in helping patients understand their
treatment options.
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A POLST conversation does not always result in a completed POLST form. It
may take multiple conversations with a patient before they are ready to document
their wishes on a POLST form.
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
Page 9 of 11
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A completed POLST form is not the only outcome of the conversation. Instead,
gaining an understanding about what is important to the patient and where the
burdens of a particular treatment might outweigh the benefits for that patient can
be very helpful. Those things will affect the choices ultimately made on the
POLST form.
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Once a POLST form is completed, future discussions and changes to the POLST
form can be made more easily if a thoughtful conversation took place the first time.
Can nurse practitioners or physician assistants sign the POLST form?
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Currently, under California law, a POLST form doesn’t become an actionable
medical order unless it is signed by a physician – an MD or DO.
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Nurse practitioners and physician assistants can lead POLST conversations, but
the form must be signed by a physician to become an actionable medical order.
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Other states allow nurse practitioners to sign POLST forms. California may
pursue that down the road, but for now, a physician must sign the form.
Our hospital will not honor a POLST form signed by a physician without
privileges at our hospital. Could you address that?
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State law requires that it be honored.
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The attending physician should do an assessment and create a new POLST
form, or use the hospital’s inpatient code status form, to document the patient’s
wishes.
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Non-physician staff should follow the orders in the POLST form until a staff
physician does an assessment of the patient.
I’m a nurse at a nursing home. I could never get the medical director to sign this
form. How am I supposed to make it happen?
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Nursing homes are adopting the POLST rapidly because it improves their end-oflife care and enables them to provide greater continuity of care between settings.
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Most have policies and procedures in place to ensure prompt physician review of
POLST forms.
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Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
Page 10 of 11
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I’d encourage you to speak with your medical director and implement a POLST
policy if one doesn’t exist now. Once a solid protocol is developed, it will make
things easier for everyone.
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There are model policy and procedure guidelines on the POLST web site:
www.caPOLST.org.
How is POLST used in Assisted Living and Residential Care Facilities? If a
patient has marked ‘Do Not Transfer’, does that apply in Assisted Living and
Residential Care Facilities?
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Only licensed health care professionals may implement a POLST form.
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The POLST form should be used the same way that a DNR form is used.
Emergency responders should be called for emergencies and provided with the
resident’s POLST form.
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If a resident’s wishes and physician’s orders as indicated on a POLST form go
beyond what can be provided in an RCFE, the resident must be relocated so
their wishes can be honored in a different setting.
o For example, feeding tubes are prohibited in Assisted Living. If the resident’s
POLST form calls for a feeding tube, and the resident needs one at some
point, the resident will need to be relocated to an appropriate setting.
Questions from EMTs:
What if a patient has a valid POLST form indicating DNR, but the family is
insisting that EMS ‘do everything to save them’?
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The POLST legislation provides immunity from criminal and civil action to
professionals acting on valid POLST orders.
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EMTs should follow their protocols.
A summary point you can make if there are a lot of challenging questions:
POLST does not create problems;
it uncovers problems that already exist in the health care system.
For difficult questions you are not able to answer, please contact (or refer the person to)
the Coalition for Compassionate Care of California at (916) 489-2222 or
[email protected].
*FOR INTERNAL PURPOSES ONLY - NOT FOR DISTRIBUTION*
Use Frequently Asked Questions documents on www.caPOLST.org as handouts.
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