OkPOLST stands for Oklahoma Physician Orders for Life-Sustaining Treatment. It refers to a physician’s order that documents and directs a patient’s medical treatment preferences when faced with life-limiting illnesses and irreversible conditions. The form represents a model program for end-of-life care.
The mission of OkPOLST is to improve end-of-life care in Oklahoma by creating documents and programs that promote honoring the health care wishes and goals of care of those with life-limiting and irreversible conditions.
The OkPOLST form represents the wishes and goals of care of the patient, and is translated into a physician’s order that is readily available to other health care providers that may be involved in the patient’s care. The information in the OkPOLST form is obtained from a conversation between the patient or his/her legal health care representative and his/her physician. Studies conducted in states that have similar documents available have revealed that among patients who have those documents, treatment preferences were honored 98 percent of the time, and no one received unwanted intubation, CPR, intensive care or feeding tubes. As a result, documents like the OkPOLST form have helped bridge the gap between what treatments the patient wants and what the patient receives.
Cultural and religious beliefs vary widely in regard to end-of-life care. There are many resources available to help patients determine if the OkPOLST form is right for them, based on their personal beliefs. Patients are also encouraged to discuss the form with their clergy or religious or spiritual leaders.
No. The OkPOLST form is recommended as the standard of care to be used by Oklahoma health care providers to document a physician’s orders directing a patient’s medical treatment preferences when facing life-limiting and irreversible conditions. It has the same legal standing as other physician’s orders.
No. An advance directive, also known as a ‘living will,’ is a legal document that provides instructions specifying what types of treatment should be given to a person when that person becomes unable to make decisions or can no longer speak for him/herself. It only goes into effect if the patient loses the ability to make decisions. An advance directive can be very specific or very vague.
The OkPOLST form, however, is used as part of the health care planning process and is complementary with advance directives. It may also be used in the absence of an advance directive. In addition, the OkPOLST form is a physician’s order that specifically outlines a patient’s medical treatment wishes and goals of care. As a physician’s order, it should be honored by all health care professionals, and it can be used to translate an advance directive into a physician’s order. Also, because the OkPOLST form becomes part of the patient’s medical record, it travels with the patient across health care settings. For reference purposes, those with questions about the difference between advance directives and the OkPOLST form may find the following table helpful:
|For anybody age 18 and older||For persons with advanced life-limniting illness and irreversible conditions at any age.|
|Provides instructions for future treatment||Provides medical orders for current treatment|
|Appoints a healthcare proxy||Does NOT appoint a healthcare proxy|
|Guides treatment decisions when available and the patient is incpacitated||Guides treatment decisions when available. Does not require incapacitation or “activation.”|
|Cannot be signed by a legal healthcre representative on behalf of an incapacitated person||Can be signed by a patient with capacity or if incapacitated, by the patient’s legal health care representative.|
a. 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.
b. If there are any conflicts or ethical concerns about the OkPOLST orders, appropriate hospital or health care facility resources – e.g., ethics committees, care conference, legal, risk management or other administrative and medical staff resources – may be utilized to resolve the conflict.
c. During conflict resolution, consideration should always be given to:
1) the attending physician’s assessment of the patient’s current health status and the medical indications for care or treatment;
2) 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
3) the patient’s most recently expressed preferences for treatment and the patient’s treatment goals.
While all three forms are not required, it is recommended that patients with life-limiting and irreversible conditions have an advance directive that appoints a health care proxy or a health care durable power of attorney and an OkPOLST form directing a health care provider on his/her medical treatment preferences at the end of life.
The OkPOLST form should be reviewed when the patient is transferred from one health care setting to another; when the patient experiences a significant change in condition; and/or when the patient’s treatment preferences change. The form includes a section that records when and why the form was reviewed and whether any changes were made. The OkPOLST form is designed to be a living document and should always reflect the patient’s most recent wishes for medical treatment and goals of care.
Yes, the form can be revoked at any time by the patient or their legal proxy.
Yes. The OkPOLST form addresses cardiopulmonary resuscitation, or CPR, in Section A. The orders specified in this section are applied only when the patient has no pulse and is not breathing, and do not apply to any other medical circumstances. If the patient wants CPR in this situation, those wishes are specified in this section, and full CPR measures will be performed. If the patient does not want CPR in this situation, he/she may choose the ‘Do Not Resuscitate’ option, which means CPR will not be performed and defibrillators will not be used. The patient should understand that comfort measures will always be provided if the ‘Do Not Resuscitate’ option is selected.
DNR stands for ‘Do Not Resuscitate.’ It means that no attempts will be made to restart the heart or breathing if the patient has no pulse or respiration.
Comfort measures only means the care and treatment provided will be for the purpose of enhancing comfort, controlling pain and symptoms and relieving the patient’s suffering. Positioning and wound care will be used to relieve the patient’s pain and suffering. The use of pain medication, oxygen, oral suction and manual treatment of airway obstruction will also be used as needed to ensure comfort. Measures such as Continuous Airway Pressure, or CPAP, which uses mild air pressure to keep the airways open, and Bilevel Positive Airway Pressure, or BiPAP, which is a breathing apparatus that helps the patient get more air into his/her lungs, may also be used to provide comfort.
Full treatment refers to all appropriate life-sustaining treatments and may include the use of intubation, advanced airway intervention, mechanical ventilation, cardioversion, transfer to hospital, and use of intensive care, as indicated. It also means that in medical emergencies, 911 is called.
Yes. The form includes a section that allows the patient to decide whether or not he/she wants nutrition and fluids by tube or IV. The form also allows the patient to state whether he/she would prefer a trial period, or if he/she wants long-term artificially administered nutrition and fluids.
Food and water are provided by mouth whenever possible. This is clearly indicated in bold print in Section D of the OkPOLST form. If a patient is no longer able to eat and drink because of an illness from which he/she is not expected to recover, then continued discussions need to occur about the burden versus the benefit of ‘invasive’ feeding by tube or IV versus comfort care. Comfort care would include keeping the mouth and lips moist and providing food and water by mouth as tolerated. In some cases, to persist in providing artificially administered nutrition and hydration may become unduly burdensome for the patient and is not medically indicated.
The OkPOLST form provides additional orders or comments to be added in sections B, C and D. The patient may use these sections to relay special instructions, whatever those instructions may be.
Additional information, including the POLST form, and information for consumers, health care professionals and health care organizations, is available on the OkPOLST website. A collaborative effort is underway to educate Oklahoma’s health care providers, caregivers, social workers, religious leaders/organizations, patients and consumers about the OkPOLST form.