Introduction to OkPOLST
Oklahoma Physician Orders for Life-Sustaining Treatment (OkPOLST) is an easily identifiable pink document that translates a patient’s goals of care and treatment preferences for end-of-life care into a physician order that transfers across health care settings. The OkPOLST form represents a “plan of care” for a patient with a life-limiting illness, and is modeled after the Physician Order for Life-Sustaining Treatment (POLST) Paradigm which is used in many states. For more information about the POLST Paradigm, visit www.polst.org.
The document should be completed after a thorough discussion with the patient, and if the patient is incapacitated, his/her legal health care representative* regarding the patient’s understanding of the illness, treatment preferences, values and goals of care. Completion of an OkPOLST form encourages communication between doctors and patients, enables patients to make informed decisions and clearly documents these decisions to other physicians and health care professionals. As a result, OkPOLST can help ensure that a patient’s wishes are honored, prevent unwanted or non-beneficial treatments, and reduce patient and family stress regarding decision-making.
OkPOLST does not replace an advance directive for health care (living will) but can be used to operationalize the directives of the living will. It is recommended that patients with a life-limiting illness have three (3) documents:
• OkPOLST (Oklahoma Physician Order for Life-Sustaining Treatment)
• Durable power of attorney for health care
• Advance directive (living will)
The OkPOLST form belongs to the patient and travels with the patient as he/she moves from one health care setting to another. A copy should always be kept in the patient’s chart or medical record and be immediately accessible by other health care providers as necessary in every facility to which the patient is admitted.
Please click here for a detailed video describing the OkPOLST initiative and form.
*Oklahoma statutes identify the legal health care representative to be a health care proxy named in an advance directive for health care, an attorney-in-fact named in a health care durable power of attorney or a court-appointed guardian.
Compliance with OkPOLST
In some cases, physicians have been hesitant to follow OkPOLST orders without first reassessing the person’s wishes in the current clinical situation. However, the OkPOLST Task Force recommends that OkPOLST form be followed until a review is completed by the accepting health care professional. The OkPOLST form should be followed even if the physician who has signed the document is not on the medical staff of the facility.
Health care institutions are encouraged to develop policy and procedures for the use of OkPOLST. Examples of such policies are available at www.okpolst.org and require appropriate legal consultation.
The Impact of OkPOLST
The OkPOLST program is the top priority of the OkPOLST Task Force as research has shown that documents like OkPOLST are making a difference in end-of-life care. It serves as a useful tool for starting a dialogue with patients regarding their wishes about end-of-life care.
Studies in states that have POLST available have revealed that among patients with completed POLST documents, treatment preferences were respected 98% of the time, and no one received unwanted CPR, intubation, intensive care or feeding tubes. As a result, POLST has helped to bridge the gap between what treatments patients want and what they receive.
OkPOLST and the Advance Directive
OkPOLST can be used as a “stand alone” document. It also complements but does not replace an advance directive for health care. An advance directive allows individuals to document the type of medical care that is acceptable in life-limiting and irreversible conditions and is usually completed in advance of any illness. The advance directive can only be used when the patient is unable to speak for him/herself. It provides a broad outline of a patient’s wishes relating to end-of-life care and may be filled out by any capacitated person 18 years of age or older, regardless of one’s health status. An advance directive is not a physician order, requires interpretation and is often unavailable when needed.
For seriously ill/frail, at any age
For anyone 18 and older
Specific orders for current treatment
General instructions for future treatment
Can be signed by legal health care representative
Appoints a legal health care representative
Provides guidance for emergency medical personnel
Does not guide emergency medical personnel
Travels with a patient across health care settings
Difficulty locating AD during times of crisis
Algorithmic document outlines medical treatment preferences
Sometimes difficult to interpret
Becomes effective when the form is signed by patient and provider
Becomes effective when a patient cannot speak for himself/herself
In contrast, OkPOLST is designed for those with life-limiting and irreversible conditions and identifies the specific wishes of a patient regarding medical treatments. With the appropriate signatures, the OkPOLST form may be used for any person who has a life-limiting and irreversible condition regardless of age.
Since the OkPOLST form travels with patients when they move from one residential or medical setting to another, it ensures that the physician orders travel with them. OkPOLST provides clear direction about a patient’s end-of-life health care treatment wishes for physicians, nurses, emergency responders, and other health care providers wherever they are.
Discussing OkPOLST with Patients
Conversations with patients about the type of care they would like to receive as their disease progresses are important. The OkPOLST form provides a context for guiding the conversation and makes it more likely that patients will express their treatment wishes and goals of care.
The completion of the OkPOLST form involves a thorough discussion between patients and physicians with physicians responsible for the completion of the document. Other members of the health care team - nurses, social workers, or chaplains - may also be involved in the conversation about end-of-life care, particularly to address physical, psychosocial and spiritual issues that often arise.
Because the OkPOLST form establishes medical orders, a physician must sign the document for it to be valid. The patient or, if the patient is incapacitated, his/her legal health care representative must sign as well to confirm that the orders were discussed and agreed upon. Once signed by both the physician and patient, OkPOLST becomes part of the patient’s medical record. It can be revoked at any time based on new information or changes in a patient’s condition or treatment preferences.
A sample conversation with a patient about OkPOLST may sound like this:
“I’d like to talk to you today about what is going on with your medical condition which will help me understand how to best care for you or your family member. We will need to discuss the types of treatments available, what will work, what might work, and what will not work and what your goals of care are. After we have that conversation, we will be able to complete an OkPOLST form which is a physician’s order that outlines the plan of care we discussed. This order will communicate this important information to other members of the health care team so they know how to best care for you during your illness. This document will transfer with you across care settings (hospital to home to nursing home, hospice). The OkPOLST form can be rewritten at any time as long as it represents your wishes and goals of care.”
The OkPOLST form is a two-sided pink form. One side of the document contains a physician order set for life-sustaining treatment (Sections A – E) and the required signature of the physician and the patient or his/her legal health care representative. The other side of the document lists additional instructions as well as how to review, rewrite or void the document. Completion of an OkPOLST form is voluntary, and the purpose of the document is to ensure that the patient receives the level of medical care he/she desires regardless of care setting. In institutional settings, the OkPOLST should be the first document in the clinical record.
When a person with an OkPOLST form is transferred from one setting to another – for example, from a long-term care facility to a hospital – the original document should accompany that person. A copy of OkPOLST, however, should always be kept in the individual’s medical record. Photocopies and faxes of signed OkPOLST forms are legal and valid. HIPAA permits disclosure of OkPOLST to health care professionals across treatment settings.
Reviewing the Document
It is recommended that OkPOLST be reviewed periodically. Review is recommended when:
• The patient is transferred from one care setting or level of care to another;
• There is a substantial change in the patient’s health status; or
• The patient’s treatment preferences change.
Rewriting / Voiding the Document
A patient with capacity can rewrite or void the OkPOLST form at any time or change his/her mind about treatment. To void an OkPOLST form, draw a line through Sections A through D and write “VOID” in large letters. This must be signed and dated. If the patient no longer has decision-making capacity, the legal health care representative may void and/or rewrite the OkPOLST form if there is new knowledge of a change in the patient’s wishes or medical condition.
Completing the OkPOLST form
The introductory section on the front of the document includes comments about the OkPOLST order and the requirements for health care provider and physician action. Patient identifying information must be entered at the top of the form.
The OkPOLST form is divided into five sections.
A. Cardiopulmonary Resuscitation (CPR)
B. Intubation and Mechanical Ventilation Instructions
C. Medical Interventions
D. Artificially Administered Fluids and Nutrition
E. With whom the choices were discussed and existence of an advance directive (if available)
For the OkPOLST form to be valid, the time and dated signature and contact information of physician and the signature of patient or his/her legal health care representative is required.
If a patient requires treatment, the first responder should initiate any treatment orders recorded on the OkPOLST and then contact the patient’s physician, as indicated.
Any section not completed; full treatment should be provided for that section until clarification is obtained.
A thorough discussion of each section and how to complete them is provided in the following pages. Patients should be advised that measures to provide comfort care will always be given, regardless of the level of medical care desired.
Section A: Cardiopulmonary Resuscitation (CPR)
These orders apply only when the patient has no pulse and is not breathing. This section does not apply to any other medical circumstances.
This section also does not apply to a patient in respiratory distress (because he/she is still breathing) or to a patient who has a pulse and low blood pressure (because he/she has a pulse). For these situations, the first responder should refer to section B and follow the indicated orders.
If the patient wants CPR and CPR is ordered, then the “CPR /Attempt Resuscitation (full code)” box is checked. Full CPR measures should be performed, and 911 should be called. If “CPR /Attempt Resuscitation (full code)” is chosen, then the “Full treatment” box under Section C should also be checked.
If a patient has specified that he/she does not want CPR in the event of no pulse and no breathing, then the “DNR/Do Not Attempt Resuscitation (Allow Natural Death)” box is checked. CPR should not be performed. No defibrillator (including automated external defibrillators-AED) should be used on a patient who has chosen “DNR/Do Not Attempt Resuscitation.”
The patient should understand that comfort measures will always be provided and that CPR will not be attempted.
Section B: Intubation and Mechanical Ventilation Instructions:
These orders apply to emergency medical circumstances for a patient who is DNR, and has progressive or impending pulmonary failure without acute cardiopulmonary arrest. The patient may select Do Not Intubate (DNI) in the event of respiratory failure, or Attempt a trial period of intubation and ventilation or Attempt a trial period of non-invasive ventilation such as BiPAP. Additional instructions can be added to further define the patient’s wishes in this section.
Section C: Medical Interventions:
These orders apply to emergency medical circumstances for a patient who has a pulse or is breathing.
Comfort Measures only as per physician orders: indicates a desire for only those interventions that enhance comfort. These may include use of medication by any route, positioning, wound care, oxygen, suction and manual treatment of airway obstruction (choking) as needed for comfort and other measures to relieve pain and suffering.
In some limited situations, BiPAP or CPAP may be considered as a time-limited comfort intervention. Transfer to a hospital or another setting may be necessary if comfort needs cannot be met in the current location. Examples of this might include pain relief, control of bleeding, wound care to treat and improve hygiene, positioning for comfort, manual airway opening and stabilization of fractures including surgery. The goal is to control pain and other symptoms. In some cases, parenteral medication to enhance comfort may be appropriate for a patient who has chosen “Comfort Measures Only.” Treatment of dehydration is a measure which may prolong life. A patient who desires IV fluids should indicate “Limited Additional Interventions” or “Full Treatment.”
Limited Additional Interventions includes comfort measures as well as medical treatment and cardiac monitoring, if needed. This order is also used to indicate treatment for those with short-term dehydration or other fluid needs. Also labs, diagnostic tests, additional medication, IV fluids as ordered, blood products and antibiotics may be ordered with comfort as a goal. Intubation, advanced airway interventions and mechanical ventilation are not used, though non-invasive positive airway pressure may be used. This includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP) and bag valve mask (BVM) assisted respirations. The benefits of the treatment should outweigh burdens of treatment.
If all life-sustaining treatments are desired, the “Full Treatment” box is checked and all care above is administered with no limitation of treatment as medically indicated. In medical emergencies, 911 is called. All support measures needed to maintain and extend life may be utilized – including intubation, advanced airway intervention, mechanical ventilation, electrical cardioversion, transfer to hospital and use of intensive care, as indicated. If the person chooses some limitation, then a different box is checked.
It is recommended that health care professionals first administer the level of medical care delineated and then contact the patient’s physician. Comfort care is always provided regardless of level of medical care desired. Other instructions may also be specified.
Ordering antibiotics may fall under Comfort Measures Only, Limited Additional Interventions or Full Treatment. Antibiotics have an important place in the treatment of many infectious diseases. They may be used to cure, to prolong life and/or to provide comfort, but they may also increase burden without benefit.
This is particularly important when patients have advanced dementia or other neurologically devastating illness and contract a urinary tract infection or aspiration pneumonia as part of the death spiral. They are treated with antibiotics, then have recurring illness in six weeks - the next time, infection occurs within three weeks, then recurs again within one week. Each recurrence brings greater debility and antibiotic resistance.
At some point, the decision should be made to determine the use or limitation of antibiotics when infection occurs with comfort as the goal. Physicians in conjunction with the rest of the team and family should have conversations concerning this decision.
Section D: Artificially Administered Fluids and Nutrition
It is recommended that oral fluids and nutrition be offered to the patient if medically feasible and tolerated. Oklahoma Law requires that hydration and nutrition by tube be provided to a patient unless the patient refuses this treatment or it causes intractable pain or is not medically possible to provide. If the patient is incapacitated, death is imminent and death will not result from starvation or dehydration, AHN (artificial hydration and nutrition) is not required. In all other conditions, consent must be obtained in order to withhold or withdraw this medical treatment.
In patients who are dying, AHN may be excessively burdensome to the patient and may provide little or no benefit. In patients with chronic conditions, AHN may not be expected to prolong life, is excessively burdensome, and may cause significant physical discomfort.
This is a clinical judgment between a patient or his/her legal health care representative and the physician. By checking the appropriate box in this section, the patient or the legal health care representative may request AHN be withheld or withdrawn if in his/her judgment the treatment suggested does not offer a reasonable hope of benefit or places an excessive burden on the family or the community.
If long-term AHN by tube is medically indicated and desired by the patient, then the appropriate box is checked.
In some cases, a defined trial period of artificial nutrition by tube can allow time to determine the course of an illness or allow the patient an opportunity to clarify his/her goals of care.
Section B, C, and D provide space for comments or additional orders:
These sections provide an opportunity for the physician to write other orders and the patient to relay any special instructions, whatever those instructions may be. For example, some patients with chronic obstructive pulmonary disease (COPD) may want to go to the hospital for bi-level positive airway pressure (BiPAP), or they may prefer to be on a ventilator one more time for three days.
These sections provide a place for patients to document those types of specific wishes regarding particular treatments that are important to them or their families.
Section E: The above choices were discussed with:
Upon completion of the orders, the physician checks the box indicating with whom the orders were discussed - the patient or his/her legal health care representative.
Advance Directive (if available)
The appropriate box should be checked if the patient has an advance directive such as the appointment of a health care proxy, a living will or a durable power of attorney for health care. A copy of these documents should be placed in the patient’s chart and/or electronic medical record.
It is the responsibility of the attending physician to determine whether the POLST document conflicts with any advance directive and with the patient or his/her legal health care representative’s input, and document the resolution of any conflict.
The physician and the patient (or legal health care representative) must sign and date the document. This acknowledges that the orders are medically indicated and consistent with the patient’s (or legal health care representative’s) understanding of his/her illness, treatment preferences, values, and goals of care. Additional information supporting these orders should be placed in the medical record.
The orders are not valid without the physician and patient or legal health care representative signature, date, and physician phone number. If signed by the legal health care representative, the relationship and authority to act on behalf of the patient must be documented.
If the OkPOLST conflicts with the patient’s previously-expressed health care instructions or advance directive, then, to the extent of the conflict, the most recent expression of the patient’s wishes are honored.
If there are any conflicts or ethical concerns about the OkPOLST orders, appropriate resources – e.g., ethics committees, care conference, legal, risk management or other administrative and medical staff resources – may be utilized to resolve the conflict.
During conflict resolution, consideration should always be given to:
a) the attending physician’s assessment of the patient’s current health status and the medical indications for care or treatment;
b) the determination by the physician as to whether the care or treatment specified by OkPOLST is medically ineffective, non-beneficial, or contrary to generally accepted health care standards; and
c) the patient’s most recently expressed preferences for treatment and the patient’s treatment goals.
Click on the downloads section to download a copy of the OkPOLST form. Please note: Ideally, the OkPOLST form should be printed on pink paper.