1. Physician Orders for Life Sustaining Treatment
What is POLST?
Physician
Orders for
Life
Sustaining
Treatment
POLST is an acronym that stands for Physician Orders for Life-Sustaining Treatment. It is a medical order that gives patients more control over their care by specifying the types of medical treatment they want to receive during serious illness.
POLST:
encourages communication between healthcare providers and patients.
enables patients to make more informed decisions.
clearly communicates these decisions to healthcare providers.
As a result, POLST can:
prevent unwanted or medically ineffective treatment.
reduce patient and family suffering.
help ensure that patient wishes are honored.
Use of the form began in California in 2008, and became part of state law on January 1, 2009.
[INSTRUCTORS: This slide presentation has been developed for your use. Materials are copyrighted by the Coalition for Compassionate Care of California. Please adapt to meet your needs and tailor to your audience and time allotted for presentation. If you have any questions, contact POLST Program Director with the Coalition for Compassionate Care of California at (916) or coalitionccc.org.]

2. Why POLST? Patient wishes often are not known.
The Advance Health Care Directive (AHCD) may not be accessible.
Wishes may not be clearly defined in AHCD.
The AHCD is not a physician order.
Allows healthcare providers to know and honor wishes during serious illness.
So why do we need POLST in California?
Studies have shown that patient wishes about care are often not known.
Even when a patient has an Advance Health Care Directive, it may not be accessible when needed.
Also, advance directives are not always clearly defined and are not a medical order.
The POLST form is clear about wishes and easy to access and read. Plus, it is an actionable medical order that healthcare providers can follow.
The POLST form allows healthcare providers to know patient wishes in the event of a serious illness, and to honor them.

3. Patient Story: What We Know
Let’s take a look at a typical story that may be familiar to you.
Mr. Jones is an 83-year-old man with severe congestive heart failure (CHF).
He is living in a skilled nursing facility (SNF) after a hospital stay for pneumonia.
He developed increasing shortness of breath and decreased responsiveness.
The SNF staff called 911 for patient transport to the hospital.
The emergency department physician couldn’t find any code status information in the paperwork sent by the SNF and wrote “Full Code.”
Mr. Jones required intubation and was transferred to the intensive care unit.

4. Patient Story: What We Didn’t Know
Here’s what we didn’t know:
Mr. Jones had an Advance Health Care Directive.
It wasn’t with the paper work that was sent to the hospital.
It was at his home.  He had been asked about it on admission, but his family hadn’t brought it in to add to his SNF medical record.
Mr. Jones had talked with his family and the SNF staff about his desire not to go back to the hospital and that he didn’t want to receive any aggressive treatment. 
There was documentation of this in the nurses notes at the SNF, but not in any documentation that was sent to the hospital.
Mr. Jones’ family could not be reached.
[Note re: AHCD Kit image:  © California Medical Association 2017 (latest version).  Published with permission of and by arrangement with the California Medical Association.  More information regarding advance health care directives and related issues can be found in CMA’s California Physician’s Legal Handbook, which contains legal information on a variety of subjects of everyday importance to practicing physicians.  CMA’s Advance Health Care Directive Kit and California Physician’s Legal Handbook may be obtained from CMA Publications at (800) or CMA’s online bookstore at
©California Medical Association 2017

5. Patient Story: What Happened
AHCD not transferred with patient
DNR wishes not documented
Over-treatment against patient wishes
Unnecessary pain and suffering
So what happened in our story?
The Advance Health Care Directive was not transferred with the patient. The SNF didn’t have it so they couldn’t transfer it.
Mr. Jones’ “Do Not Resuscitate” wishes were not documented in a way that was easily found by staff. When he was transferred from the acute care hospital to the SNF, there were no code status orders with the transfer papers.
Mr. Jones received over-treatment which went against his wishes.
Because of this, he experienced unnecessary pain and suffering.
There was a system-wide failure to document and honor the patient’s wishes. There was not a consistent, recognizable plan in place. Mr. Jones wishes were not communicated to all medical systems, including acute care hospital, Emergency Medical Services (EMS), and the SNF.
[REFERENCE: Case study adapted from Lynn, Joanne; Goldstein, Nathan. Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwarranted Suffering. Annals of Internal Medicine, Vol. 138, Issue 10, May 20, 2003, pages ]

6. What is POLST?
A medical order recognized throughout the medical system
Portable document that transfers with the patient
Brightly colored, standardized form for entire state of California
So, what is POLST? [INSTRUCTORS: Pull out your POLST form to show]
It is a medical order that is recognized throughout the medical system.
It is a portable document that transfers with the patient from one care setting to another.
It is easily distinguished by its bright pink color.
It is a standardized form for the whole state.

7. What is POLST?
Allows individuals to choose medical treatments they want to receive, and identify those they do not want
Provides direction for healthcare providers during serious illness
POLST provides direction for a range of medical treatments during serious illness, so that healthcare providers can provide the treatments patients do want, and avoid those that they do not want.
We’ll take a look at the POLST form itself in a moment.

8. Who Would Benefit from Having a POLST Form?
Chronic, progressive illness
Serious health condition
Medically frail
Tool for determination
“You wouldn’t be surprised if this patient died within the next year”
Who would benefit from having a POLST form?
POLST is designed for those who:
Have a chronic progressive illness,
Have a serious health condition, or
Are medically frail.
Someone not fitting into one of those categories may have a POLST form if that person and their physician agree that it would be a good idea to have one.
There are no age specifications. POLST can be used with both adult and pediatric patients.
A helpful tool for determining who would benefit from POLST is the question, “Would you be surprised if this patient died within the next year.”
This question reflects that determination of who’s appropriate for POLST is an art, not a science.

9. POLST History POLST development began in Oregon in 1991
Expanded to more than half of the United States
Let’s take a look at a brief history of POLST. It has existed for many years.
POLST has been used in Oregon since 1991.
It was developed initially for SNF patients who are often transferred from one care setting to another - mainly from the SNF to acute care and back to the SNF or to home.
More than one million forms have been distributed in Oregon.
POLST is used by all Oregon hospices and 95% of nursing homes.
The use of the POLST form has now expanded to most of the US – we’ll take a look at a map in a moment.
Some states have used state regulation to help with POLST implementation. Others, such as California, have enacted POLST legislation to move POLST forward as a statewide standard of practice. Many states have established POLST as a community standard of practice (without any statute or regulation).

10. National POLST Paradigm Programs
*As of June 2018
Here is the map of POLST program status across the United States. The National POLST Paradigm Task Force evaluates state POLST programs and, based on specific criteria, designates the programs as developing, endorsed or mature.
In 2016, California joined Oregon and West Virginia as one of only three states which have been endorsed by the POLST Paradigm Task Force as a Mature POLST program (since that time, Oregon has separated from the National POLST organization). Mature status is the highest level of endorsement and is reserved solely for states with statewide POLST programs that, among other requirements, are the standard preferred method of advance care planning for persons with advanced illness or frailty. Mature POLST programs are used by 50% or more of hospitals, nursing homes or nursing home resident population, and hospices in each region of the state. These programs are actively gathering data for quality assurance programs and have considered centralized POLST databases. The Mature states are depicted by the darkest pink color on this map.
Endorsed POLST programs are the medium pink states, which have statewide or regional POLST programs which are part of routine advance care planning in that area. There are 22 endorsed states. These programs have addressed POLST legal and regulatory issues, as well as developing implementation and quality assurance strategies.
The 24 pale pink states have Developing POLST programs. These states have submitted their POLST form to the National POLST Paradigm Task Force. Developing POLST programs may be at various stages of development, with the goal of working towards implementing the POLST program across the state.
The POLST system continues to develop across the United States. Information about the National POLST Paradigm program can be found at
Mature Programs (2)
Endorsed Programs (22)
Developing Programs (24)
Programs That Do Not Conform to POLST Requirements (4)
No Program/Contacts (1)

11. Oregon Study: Location of Death and POLST Orders
POLST Success
Oregon Study: Location of Death and POLST Orders
58,000 deaths reviewed, 31% had POLST in Oregon Registry
Patient treatment choices honored, including avoiding dying in hospital
There have been several studies showing how well POLST works in allowing providers to honor patient wishes.
A recent Oregon study looked at the relationship between POLST treatment choices and the care setting (home, hospital or SNF/Assisted Living) at the time of death. Of the 58,000 deaths reviewed, 17,902 (31%) had a POLST form in the Oregon POLST Registry.
In-hospital death for patients with Comfort Measures Only was 6.4%.
For patients requesting Full Treatment, 44.2% died in hospital and for Limited Interventions, 22.4% died in hospital.
For those with no POLST form in the registry, 34.2% died in the hospital.
The study found those who died with POLST Comfort Measures Only orders were significantly less likely to die in the hospital, compared to those requesting Full Treatment.
Full Treatment patients were almost 10 times as likely to die in the hospital than Comfort Measures Only patients.
Limited Interventions patients were 4 times as likely to die in the hospital than Comfort Measures Only patients.
[REFERENCE: Fromme, E. K., Zive, D., Schmidt, T. A., Cook, J. N. B. and Tolle, S. W. (2014), Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon. Journal of the American Geriatrics Society. doi:  /jgs.12889]
[INSTRUCTORS: The California POLST form used the terms “Limited Additional Interventions” and “Comfort Measures Only” in the 2009 and 2011 versions. The October 2014 CA POLST version uses the terms “Selective Treatment” and “Comfort-Focused Treatment.”]
Fromme EK, JAGS 2014

12. POLST in California
The Coalition for Compassionate Care of California (CCCC) is lead agency
Support from California Health Care Foundation
Grassroots efforts of local POLST coalitions and communities
Let’s take a look at what is happening with POLST in California.
The Coalition for Compassionate Care of California (CCCC) is the lead agency for POLST in California, and is focused on implementing POLST as a community standard of practice.
CCCC is working with more than 30 local POLST coalitions around the state which have received support from the California Health Care Foundation to promote POLST outreach and education efforts in their communities.
This grassroots approach to POLST implementation is one of the hallmarks of the California POLST paradigm.

13. POLST in California Assembly Bill 3000 Original POLST legislation
Effective January 1, 2009
Assembly Bill 637
Authorizes NPs and PAs to sign POLST
Effective January 1, 2016
POLST went through the legislative process as California Assembly Bill 3000.
It was championed by Senator Lois Wolk of Yolo County and was supported fully by our legislators around the state – it passed unopposed.
It was signed by Governor Schwarzenegger in August of 2008 and became law in California effective January 1, 2009.
Another important piece of POLST legislation, Assembly Bill 637, was passed in 2015 and became effective January 1, This bill authorizes nurse practitioners and physician assistants, acting under the supervision of a physician and within their scope of practice, to sign POLST forms.

14. POLST in California One form for entire state Use not mandated
Honoring form is mandated
Provides immunity from civil or criminal liability
AB 3000, Wolk. Part 4, Sec 7, Probate Code Section 4782
Some of the key points in the bill to be aware of:
There is one form for the entire state.  This is an important requirement for POLST to work. How many forms do we have from one SNF to another, or one hospital to another that are the same? Not many!
POLST is completely voluntary for patients. It is the patient’s choice whether they have one. And, it’s the patient’s choice as to the treatment options selected on the form.
If a patient has a POLST form, however, healthcare providers must honor it.
It is not mandatory for anyone to use the form, but honoring the form is mandatory! We must recognize the POLST form and honor the patient’s wishes.
Providers must honor POLST even if ordering physician does not have admitting privileges at facility.
The physician providing care conducts a new assessment of the patient, reviews POLST, and writes inpatient orders if admitted.
Providers must follow POLST wishes except if contrary to generally accepted healthcare standards or medically ineffective treatment. An example is if someone is critically ill and treatments requested on the POLST form either will not help the person or can cause more harm, the doctor will discuss the appropriate plan of care with the patient and/or family. [REFERENCE: AB 3000, Part 4, Section 4, Probate Code Section ]
POLST law protects healthcare providers who comply in good faith with a patient’s POLST requests. [REFERENCE: AB 3000, Part 4, Section 7, Probate Code Section 4782 – “A healthcare provider who honors a request to forgo resuscitative measures is not subject to criminal prosecution, civil liability, discipline for unprofessional conduct, administrative sanction, or any other sanction...”]

15. POLST vs. Advance Health Care Directive
POLST complements the Advance Health Care Directive (AHCD)
POLST is not intended to replace the AHCD
Both are legal documents
AB 3000, Part 4, Sec 3, Probate Code 4780 (3) (c)
Does POLST replace the advance directive? Absolutely not!
POLST aims to turn the values and wishes expressed in a person’s AHCD into actionable medical treatment orders that can be easily understood and followed by healthcare providers, including EMS.
In California, the term Advance Health Care Directive includes both the Durable Power of Attorney for Healthcare and the Living Will.
[REFERENCE: AB 3000, Part 4, Section 3, Probate Code Section 4780 (3) (c) “The healthcare provider, during the process of completing the POLST form, should inform the patient about the difference between an advance health care directive and the POLST form.”]

16. POLST vs. Advance Health Care Directive
AHCD
For seriously ill/frail, at any age
Medical orders for medical treatment
Can be signed by decision-maker
For anyone 18 and older
General instructions for treatment
Appoints decision-maker
POLST is designed for people who:
Have a chronic progressive illness
Have a serious health condition, or
Are medically frail
POLST:
Someone not fitting into one of those categories may have a POLST form if that person and their physician agree that it would be a good idea to have one.
Is a medical order that documents wishes for treatment at this point in time; provides guidance to emergency medical personnel; usually completed in a medical setting.
There is one, standard form for California.
Advance Health Care Directive:
Everyone 18 years and older should be encouraged to have an AHCD.
Is a legal document completed in advance that allows you to:
make general statements about your health care wishes in the future, and
appoint a healthcare decision-maker to speak on your behalf, if you are unable to speak for yourself. Only you can complete an AHCD and name your decision-maker.
There are multiple California AHCD forms available and all are recognized and valid.

17. Advance Care Planning Continuum
Where Does POLST Fit In?
Advance Care Planning Continuum
Age 18
Complete an Advance Directive C O N V E R S A T I
Update Advance Directive Periodically
Diagnosed with Serious or Chronic, Progressive Illness (at any age)
This slide shows where POLST fits into the Advance Care Planning Continuum.
Starts at age 18 with completing an AHCD.
Your AHCD should be updated periodically – check names, contact information, and healthcare wishes.
If you are diagnosed with a serious or chronic, progressive illness at any age, talk with your physician/NP/PA about completing a POLST form.
The goal is that your treatment wishes are honored.
What is the word along the left side? 
An ongoing conversation over the years with your healthcare decision-maker, family and healthcare provider is very important.
Complete a POLST Form
Treatment Wishes Honored

18. POLST vs. Pre-Hospital DNR (Do Not Resuscitate)
Similarities:
Medical orders
Address Do Not Resuscitate
Intended for medically frail or those with chronic or serious illness
Let’s take a look at the similarities and differences between the POLST and the Pre-Hospital DNR.
Both forms are medical orders.
Both address Do Not Resuscitate if you are not breathing and your heart is not beating.
Both are for the medically frail or those with chronic or serious illness.
The Pre-Hospital DNR form was developed by the California Emergency Medical Services Authority to instruct EMS personnel to forgo resuscitation attempts in the event of a patient’s cardiopulmonary arrest. The form is designed for use in pre-hospital settings, such as:
The patient’s home.
Long-term care facilities.
During transport from a healthcare facility.
In other locations outside the acute care hospital.

19. POLST vs. Pre-Hospital DNR (Do Not Resuscitate)
Allows for choosing resuscitation
Allows for other medical treatments
Honored across all healthcare settings
Can only use if choosing DNR
Only applies to resuscitation
Only honored outside the hospital
There are differences between the two forms however. 
POLST:
Allows for choosing resuscitation in addition to saying no to it.
Allows for decisions about other medical treatments, such as treatment during serious illness and artificial nutrition.
Is honored across all healthcare settings (in the SNF, clinics, hospitals, home, EMS system, etc.)
The Pre-Hospital DNR is a medical order that is honored outside of the hospital only (home, assisted living, SNF, EMS system).
POLST is more comprehensive than the DNR form.
A DNR medallion or bracelet may be purchased with either a signed Pre-Hospital DNR form or POLST form.  One resource is the California Emergency Medical Services Authority for more information on medallions. See #4 under EMSA FAQs at

20. POLST vs. PIC (Preferred Intensity of Care)
Consistent form for California
Is a medical order
Honored across all healthcare settings
PIC form is different in every SNF
Is not a medical order; similar to a doctor’s note
Only used within the SNF
Let’s look at the differences and similarities between the POLST and the PIC (Preferred Intensity of Care) or PIT (Preferred Intensity of Treatment), which is used to document the wishes of SNF residents.
The differences are that:
The POLST is a consistent form throughout the state of California. The PIC form is different in every SNF.
The POLST form is a medical order that is honored in all healthcare settings.
Both POLST and PIC forms address medical intervention options.
PIC forms are not medical orders. They are usually signed by the physician but they are similar to a doctor’s note.
And the PIC form does NOT transfer to other settings.

21. POLST vs. PIC (Preferred Intensity of Care)
Both include choices for medical interventions.
POLST can replace the PIC form at SNF.
POLST is a voluntary form.
The POLST form can replace the PIC form in SNFs.
POLST is a voluntary form. For nursing home residents who don’t want to complete a POLST, the SNF will need to establish another process for documenting the patient’s treatment wishes in the medical record.
At discharge from the SNF, the patient can choose to take POLST home and follow-up with his/her primary care physician, OR the patient can choose to VOID the POLST form at the time of SNF discharge. We will discuss voiding a POLST form later in the presentation.

22. Let’s take a look at the form itself – please pull out your copy of the form, and we will look at the different sections.
What stands out about the look and feel of the form?
Ultra Pink
Card stock 65# paper
If making copies, please use Ultra Pink paper so POLST is easily found and recognized, especially in an emergency. POLST will be honored on any color paper, however.

23. POLST is a two-sided form, with all the required information located on the front of the form. It is important, however, to complete all the sections on the back as well, including the patient demographic information.
Minimum Requirements:
Patient Last Name
Patient First Name
Patient Date of Birth
Selection in Section A and/or Selection in Section B
Signature of Physician/NP/PA
Name and Signature of Patient or Legally Recognized Decision-maker
A Date – Any of: Date Form Prepared, Date Physician/NP/PA Signed or Date Patient or Decision-maker Signed
No Conflict: If “Attempted Resuscitation” is selected Section A, “Full Treatment” must be selected in Section B
Additional Helpful Information:
Patient Mailing Address
Phone Contact Number
Patient Gender (Male or Female)
Last 4 Digits of Patient’s Social Security Number
And remember to fax or copy both sides.
Let’s take a closer look at the different sections of the form…

24. CA POLST Form – Front Side
Here we see the top section of the front side.
What does it say at the top in the black box?
HIPAA permits disclosure of POLST to other healthcare providers as necessary.
What is the logo in the upper left hand corner?
California Emergency Medical Services Authority – this means that EMS must honor the form and take action based on the patient wishes stated on the form.
Below that is the effective date of the form.
Let’s take a look at the paragraph next to the EMSA logo:
First follow these orders, then contact physician/NP/PA. Note, this is underlined for emphasis.
A copy of the signed POLST form is a legally valid medical order.
Any section not completed implies full treatment for that section.
POLST complements an advance directive and is not intended to replace that document.
These are critical and important considerations for anyone using the form.
In the upper right corner, there is a place to document the patient’s name, date the form is prepared, patient’s date of birth and medical record number. It’s very important to date the POLST form so the most recent version can easily be identified in the case of conflicting documents.

25. Section A: CPR
Let’s take a look at Section A. What does Section A address?
Cardiopulmonary Resuscitation (CPR)
What must be happening with the patient for us to be taking action on this section?
The patient has no pulse and is not breathing.
Also note the statement, If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.
It’s important for the patient/family to understand that if you have no pulse and are not breathing, you are dead and not doing CPR allows a natural death.
Let’s take a look at the two choices:
Attempt Resuscitation/CPR – the key word here is attempt. As part of the conversation about POLST, it is important to educate the patient/family about CPR and the statistics about success. What does it say next to Attempt Resuscitation/CPR? Selecting CPR in Section A requires selecting Full Treatment in Section B – we’ll take a closer look at why that’s there in a minute.
The other choice is Do Not Attempt Resuscitation/DNR. What does it say next to this? Allow Natural Death. One of the instructions on the back of the form also indicates that “If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen “Do Not Attempt Resuscitation.”

26. Section B: Medical Interventions
Section B addresses medical interventions. The first thing is to establish that the patient is alive. If the patient is found with a pulse and/or is breathing, then treat as directed in Section B. A person must have a pulse to be breathing, but sometimes it is weak and difficult to detect.
There are three check boxes in this section, as well as a place to write in additional orders. NOTE: The 2014 POLST changed the order of choices for interventions to be consistent with Section A (so each section begins with the most aggressive and invasive treatment choices). Prior versions of POLST are still effective. Thus, it is essential to carefully read the POLST form and follow the patient’s wishes.
Each option in Section B includes a goal statement to help patients understand the goals of care within each option and help promote quality conversations with patients, family and/or legally recognized decision-maker.
Full Treatment – primary goal of prolonging life by all medically effective means. Includes a box which can be marked “Trial Period of Full Treatment.” This option is helpful for patients who want to try short-term ventilator support, but do not want prolonged life support, especially if they are not making progress.
Selective Treatment – goal of treating medical conditions while avoiding burdensome measures. Burdens of treatment may include complications, pain or weakness. A check box is included for SNF patients who may choose “Request transfer to hospital only if comfort needs cannot be met in current location.”
Comfort-Focused Treatment – primary goal of maximizing comfort. Care is focused on comfort, not on treating the person’s illnesses. Note the statement: “Request transfer to hospital only if comfort needs cannot be met in current location.”
The transfer statements say, “Request transfer...”, because calling 911 is a request, possibly by family or staff at a SNF or assisted living facility. A patient with decision-making capacity can still refuse transfer.
With Full Treatment and Selective Treatment, antibiotics are given in hopes of curing an infection. Antibiotics generally are not considered for Comfort-Focused Treatment, but may be used to promote comfort, for example, if the patient has a urinary tract infection.
Cardioversion = restoring the heart’s rhythm to normal by means of electrical shock or medications.
Non-invasive positive airway pressure = includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations.
Manual treatment of airway obstruction = Heimlich maneuver (abdominal thrusts for choking).
Let’s take a look at how Sections A and B work together.

27. Diagram of POLST Medical Interventions
CPR
DNR
Full Treatment*
Selective Treatment
Choosing “Attempt Resuscitation / CPR” in Section A requires choosing “Full Treatment” in Section B: Medical Interventions.
It is not acceptable to request “Attempt CPR” and “Selective Treatment” or “Comfort-Focused Treatment”. 
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.
“Do Not Attempt Resuscitation / DNR” may be chosen with any of the Medical Interventions in POLST Section B.
“DNR” may be chosen with “Full Treatment.”  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 (they have died). 
It is important to address length of treatment, severity of illness and prognosis with this option.
Ask the patient, “If you did not get better and doctors thought your chances of a good recovery were very poor, would you want to be kept alive on the ventilator?”   If the patient does not want to be kept on prolonged life support, the box under Full Treatment, “Trial Period of Full Treatment” can be checked.
Possible additional orders might relate to dialysis, chemotherapy, blood transfusions or AICDs (automatic implantable cardioverter defibrillator). Note if patient has an AICD so it can be deactivated at the end of life.
The POLST Conversation includes discussion regarding long-term intensive medical treatment. For more information see CCCC decision guides “What is CPR?”, “What is a Ventilator?” and “What is Artificial Hydration?” at
Comfort-Focused Treatment
*Consider time/prognosis factors under “Full Treatment”
“Trial Period of Full Treatment” may be checked if prolonged life support is not desired.

28. Section C: Artificially Administered Nutrition
Section C addresses long-term Artificially Administered Nutrition, such as during end-stage dementia or Parkinson’s Disease, or following a devastating illness.
Food will always be offered by mouth if feasible and desired by the patient.
Patients may choose between three options related to artificial nutrition:
Long-term artificial nutrition, including feeding tubes. Studies have shown that for individuals with late stage dementia or advanced terminal diseases, pneumonia and pressure ulcers are not prevented with tube feeding.
Trial period of artificial nutrition, including feeding tubes. The time frame or duration of the trial period is not decided ahead of time; the physician will discuss what is appropriate for the individual at the time. Also, feeding tubes includes Total Parenteral Nutrition (TPN).
No artificial means of nutrition, including feeding tubes.
NOTE: The 2014 POLST changed the order of choices for Section C to be consistent with Section A. Each section begins with the most aggressive intervention.
Prior versions of POLST are still effective. Thus, it is essential to carefully read the POLST form and follow the patient’s wishes.
The POLST Conversation goes into detail about the benefits and burdens of artificial nutrition. Also, for more information, see the CCCC decision guide “What is Artificial Hydration?” available at

29. The POLST Conversation
POLST is not just a check-box form.
The POLST Conversation provides context for patients/families to:
Make informed choices.
Identify goals of treatment.
This form is not just a check box form. A conversation with a healthcare provider is needed to discuss options for each individual patient.
For those of you who will be helping patients/families with this form, there is additional information about how to facilitate the POLST Conversation in The POLST Conversation Module.
Instead of simply asking, “What do you want?,” our role is to facilitate the POLST Conversation, and specifically explore goals of care.
Medical examples of what could happen in the future are used to help clarify goals of care and focus the conversation. For example, saying, “If you had a bad pneumonia…” transitions the discussion into Section B, Medical Interventions.

30. Section D: Information and Signatures
Notice the check boxes for who the POLST form was discussed with:
The patient, when the patient has capacity.
A legally recognized decision-maker, when the patient lacks capacity or when the patient has designated that the decision-maker’s authority is effective immediately (see back of the POLST form). We will also discuss the decision-maker in the next slide.
There are also check boxes for “Advance Directive dated ______ available and reviewed,” “Advance Directive not available” and “No Advance Directive.” This highlights the importance of asking for and reviewing a patient’s advance directive.
Ask participants: What signatures are needed for this form to become a medical order?
The patient/legally recognized decision-maker and the physician/NP/PA.
Read description to the class following Signature of Patient or Legally Recognized Decision-maker. The first sentence, “I am aware that this form is voluntary” is important.
The box “Mailing Address” is specific to where the patient receives mail, which may not be the residential address.
The “Phone Number” is ideally a cell phone, that can be accessed day or night.
“For Registry Use Only” is a place holder on pre-2017 POLST forms for future use by the anticipated establishment of a POLST Registry.
What does it say in the bottom black section of the form?
Send form with patient whenever transferred or discharged. This is an important reminder. The original POLST form travels with the patient.
Note the asterisk at the bottom that indicates previous versions remain valid.

31. Who Can Speak for the Patient?
Surrogate decision-maker/agent
Parent, registered domestic partner, guardian, conservator
Closest available relative
The legally recognized healthcare decision-maker includes anyone recognized under California law, including:
The person named in an advance directive (whether it is a verbal advance directive, which is time limited, or a written advance directive).  [REFERENCE: Probate Code Sections 4671 & 4711]
Parent of a minor, a registered domestic partner, or a court-appointed conservator or guardian.
If none of those people exist, then healthcare 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.  [REFERENCE: Cobbs v Grant, 8 Cal3d 229, 244 (1972)]
Healthcare providers should turn to the legally recognized healthcare decision-maker only if the patient lacks capacity or the patient has indicated that the decision-maker’s authority begins immediately.
For patients/residents in a facility:
Many acute care and SNF facilities have policies on decision-making with the unrepresented patient – check with your individual facility.
[REFER TO RESOURCES: California Hospital Association “Consent Requirements for Medical Treatment of Adults”; CCCC Handout “Determining the Appropriate Decision-maker”]

32. CA POLST Form – Back Side
The top of the back of the POLST form includes information for the:
Patient
NP/PA’s Supervising Physician (NOTE: The NP/PA’s supervising physician does not need to sign the POLST.  The name is listed only for reference.)
Preparer name (if other than signing physician/NP/PA).
And an additional contact – if the decision-maker is not the person signing the form or is not the healthcare agent on the advance directive, include their information under “Additional Contact.” The patient can also list another contact person here.
If there is no additional contact, check the box “none.”
This information is purely informational and is not required to be completed in order for the POLST form to be valid.  This does not appoint a healthcare decision-maker. The healthcare provider listed on the form is not signing the form as a witness. 

33. Who Can Help Complete POLST?
Healthcare providers – “licensed, certified, or otherwise authorized to provide health care in the normal course of business”
Best practice suggests use of those trained in the POLST Conversation:
Physicians
Nurses, Nurse Practitioners, Physician Assistants
Social Workers
Chaplains
Social Service Designees
Who can help a patient complete a POLST form? 
POLST law stipulates that the POLST form “shall be completed by a healthcare provider.” [REFERENCE:  AB 3000, Part 4, Section 3, Probate Code Section 4780 (3) (c)]
The term "healthcare provider" is defined by law as "an individual licensed, certified, or otherwise authorized or permitted by the law of this state to provide health care in the ordinary course of business or practice of a profession.“ [REFERENCE:  Probate Code Section 4621]
Best practice would include those who are trained in the POLST Conversation, including:
Physician – MD or DO
Nurse, Nurse Practitioner (NP), Physician Assistant (PA)
Social Worker
Chaplain
Social Service Designee if trained in the POLST Conversation
The key is to explore with patients and families their goals of care, and this requires a good understanding of the patient’s medical condition and what to expect as their disease progresses . Any questions should be referred for discussion with the patient’s physician/NP/PA.

34. Directions – Completing POLST
The back of the form also includes abbreviated directions on how the form is to be filled out and additional instructions for healthcare providers. Encourage all healthcare providers to carefully read the back of the POLST form.
Completing the POLST:
Completing a POLST form is voluntary.
California law requires that a POLST form be followed by healthcare providers, and provides immunity to those who comply in good faith.
In the hospital setting, a patient will be assessed by a physician who will issue appropriate orders that are consistent with the patient’s preferences.
When available, review the advance directive and POLST to ensure consistency, and update forms to resolve conflicts.
A legally recognized decision-maker may execute the POLST form only if the patient lacks capacity or has designated that the decision-maker’s authority is effective immediately.
POLST must be signed by patient or decision-maker and a physician/NP/PA to be valid.
Verbal orders may be obtained with follow-up signature by the physician/NP/PA in accordance with facility/community policy. Physician/NP/PA engagement in the POLST Conversation is essential, including those times when verbal orders are urgently needed.  A faxed physician/NP/PA signature is acceptable.
If a translated form is used, attach it to the signed English POLST form. 
Photocopies and faxes of signed POLST forms are legal and valid.

35. Directions – Using POLST
Any incomplete section of POLST implies full treatment for that section.
Section A:
If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen “Do Not Attempt Resuscitation.”
Section B:
When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort-Focused Treatment,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture). POLST reads, “Request transfer...” A patient with capacity can still refuse transfer.
Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations.
IV antibiotics and hydration generally are not “Comfort-Focused Treatment.”
Treatment of dehydration prolongs life. If person desires IV fluids, indicate “Selective Treatment” or “Full Treatment.”
Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel.

36. Directions – Reviewing/Modifying/Voiding POLST
This section includes specifics on reviewing, modifying and voiding the POLST form. We will go over the details on the next slide.

37. When Should POLST be Reviewed?
Transfer from one care setting to another
Change in patient’s health condition
Patient’s treatment preferences change
Patient Care Conference
Best Practice: Update POLST forms to the most current version when reviewing older POLST forms.
POLST should be reviewed when any of the following occur:
The patient is transferred to a different care setting. For example: home to acute care, SNF to acute care, acute care to home, etc.
There is a substantial change in the patient’s health condition.
The patient changes his/her mind about any of their treatment preferences.
At quarterly care conferences at SNF and at any patient care conference, the POLST should be reviewed and verified or changed as needed.
NOTE: It is recommended to update POLST forms to the most current version when reviewing an older POLST form.

38. Can POLST be Changed?
Patient with capacity can request alternative treatment or revoke a POLST at anytime.
Legally recognized decision-maker may request a change based on condition change or new information regarding patient wishes.
Can POLST be changed?
A patient with capacity can, at any time, request alternative treatment.
A patient with capacity can, at any time, revoke a POLST by any means that indicates intent to revoke.  It is recommended that revocation be documented by drawing a line through Sections A through D, writing ‘VOID’ in large letters, and signing and dating this line.
The legally recognized decision-maker may request to modify the orders, in collaboration with the physician/NP/PA, based on the known desires of the patient, or if unknown, the patient’s best interests.  A change to the POLST form must be in discussion with the physician/NP/PA, only if the patient lacks capacity, and if there is a change in the patient’s condition or if there is new information about the patient’s wishes.
A new POLST may then be initiated. The voided POLST is filed in the chart.

39. Where Should We Keep POLST?
Original pink POLST stays with patient
At SNF/Hospital:
File in medical chart (with AHCD)
Send original with patient upon return to home/SNF/hospital
Keep copy if patient transferred; review POLST upon patient’s return
The bright pink POLST form stays with the patient at all times. Consider treating POLST as part of the patient’s belongings.
SNF or Hospital:
POLST form should be kept in the patient’s medical chart – file with AHCD. May be scanned into the electronic medical record.
POLST goes with the patient from one care setting to another – keep copy in chart and send original with patient.
When/if patient returns to SNF, always review whether there were any changes made to POLST on file.
If a new POLST was completed, be sure to “Void” the old POLST form.
It is helpful to keep the POLST, along with the AHCD, in a plastic sleeve.
NOTE: Patients who live at a SNF are called “residents.” In the POLST education materials, to be consistent with the POLST form, we use the term “patient” for everyone, including those who reside at a SNF or residential care facility for the elderly (RCFE)/assisted living facility.

40. Where Should We Keep POLST?
At home:
Post in easy-to-find location (with AHCD)
Give to EMS to transport with patient
Home:
In the home setting, patients/families should be instructed to keep the POLST in an easy- to-find location, for example on the refrigerator or hanging on a wall by their bed, or with their medications.
The POLST goes with the patient if transported by ambulance; family should give the POLST to the EMS personnel.
The development of a POLST registry for California is being evaluated.
A DNR medallion or bracelet may be purchased with either a signed Pre-Hospital DNR form or POLST form. One resource is the California Emergency Medical Services Authority for more information on medallions. See #4 under EMSA FAQs at emsa.ca.gov/Forms.

41. POLST: Depth of the Process
POLST is more than a form.
POLST:
Facilitates rich conversations with patients/families.
Complements the AHCD.
Incorporates the importance of comfort.
POLST is not just “a pink piece of paper.”
The POLST Conversation is a rich discussion of patient values and preferences for intensity of medical treatments.
POLST does not replace the AHCD. During the POLST Conversation, completion of an AHCD and naming a decision-maker is strongly encouraged.
Providing comfort to everyone is a key foundation of the POLST process.

42. California POLST Project
The Coalition for Compassionate Care of California (CCCC) provides
leadership and oversight for POLST outreach activities in California, with support from the California Health Care Foundation.
C oalition for
C ompassionate
C are of
The Coalition for Compassionate Care of California is the lead organization for POLST efforts in California, with financial support from the California Health Care Foundation.
Note the four ‘C’s in the lead organization’s name.
C alifornia

43. California POLST Project
Translating an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for medical treatment.
POLST Conversation
A rich conversation with each individual patient
Community Collaboration
Integrating POLST into the community standard of care
Consistent Form
Standardized form recognized across care settings
The California POLST Project translates an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for treatment.
We have taken the four C’s and applied them to the key elements of the POLST process.
The 4 C’s show the depth and breadth of the POLST process in California:
POLST Conversation
Consistent form
Comprehensive education
Community collaboration
Comprehensive Education
To promote excellent conversational skills with patients and families

44. California POLST Form Available at www.caPOLST.org
Translations available
May be purchased from:
(bulk forms/paper)
(POLST Kit)
The current copy of the form is available to download at
Translations are available from CCCC in Armenian, Chinese, Farsi, Hmong, Japanese, Korean, Pashto, Russian, Spanish, Tagalog and Vietnamese.
English form must be signed for healthcare providers to be able to follow the orders.
Translated form should be attached behind the English version.
A Braille POLST form is also available.
[NOTE re: POLST Kit image:  © California Medical Association 2009.  Published with permission of and by arrangement with the California Medical Association.  More information regarding POLST and related issues can be found in CMA’s California Physician’s Legal Handbook, which contains legal information on a variety of subjects of everyday importance to practicing physicians.  CMA’s POLST Kit and California Physician’s Legal Handbook may be obtained from CMA Publications at (800) or CMA’s online bookstore at

45. Focus on the conversation
California POLST Form
Print on Ultra Pink, 65# card stock paper
Copies/faxes on any color paper are acceptable
Focus on the conversation
POLST should be printed two-sided on Ultra Pink, 65#, card stock paper. This is the standard for California and what providers are trained to look for.
Copies and faxes on any color paper are just as valid as the original.
The focus should be on the conversation about choices, not just the form and filling it out.

46. POLST Resources Consumer Brochure FAQs
There are several educational materials available for healthcare providers who will be leading these conversations, as well as for consumers.
Brochure for consumers
Frequently asked questions (FAQs) for consumers and healthcare providers
All are available from the Coalition for Compassionate Care of California at

47. POLST Resources Model policies and procedures
Standardized educational curriculum
Local POLST coalitions
Model policies and procedures are available for acute care, SNFs and hospice (see Resources).
A standardized curriculum including seven educational modules has been developed and used to train more than 1,000 POLST trainers in California since 2009.
More than 30 POLST coalitions are actively working on POLST implementation in communities throughout the state.
All materials can be found and downloaded for your use from CCCC at
Information about educational programs and coalition contacts are available from CCCC at by calling (916) or ing

48. Questions? What questions do you have? INSTRUCTORS:
Feel free to add your contact information to the slide. For more information/assistance answering questions, contact the POLST Program Manager at (916) or
Instructor may go through the objectives and ask review questions of the group:
What does the POLST acronym stand for? Physician Orders for Life-Sustaining Treatment.
What type of patient is POLST designed for? Chronic, progressive illness; seriously ill; medically frail; the “surprise question.”
State a difference between an AHCD and POLST. AHCD names a decision-maker. POLST is a physician order.
What is the difference between POLST and PIC? POLST is medical order and is recognized in all healthcare settings.
List two signatures required on the POLST? Patient and physician/NP/PA.