When Bernice Blickle’s husband collapsed on the floor six years ago, paramedics rushed to the couple’s Woodland home, ready to administer CPR and bring him back to life. That’s when Blickle handed them a bright-pink paper document that spelled out exactly what her husband wanted in case of a medical emergency.
Known as a POLST (short for Physician Orders for Life-Sustaining Treatment), it’s a paper form – signed in consultation with a patient and his or her doctor – that lists exactly which life-saving interventions are wanted.
For several years, the Blickles had kept their POLST forms prominently stuck to their refrigerator door, just in case.
“As soon as (paramedics) came in the door, I showed them,” said Blickle, a retired nurse. “The look on their faces was just reassuring. It was like, ‘OK, we know exactly what to do.’ ”
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POLST forms, which are available in nearly every state, were implemented in California in 2009, allowing medically frail or seriously ill people – of any age – to spell out their emergency treatment preferences. This year, two new bills took effect that usher in some changes. As of January, nurse practitioners and physician assistants are now able to sign the forms, in addition to physicians. And, to make it easier for emergency responders and hospitals to access a patient’s wishes, the state authorized an electronic registry of POLST forms.
“The goal is to honor the wishes of someone at the end of life,” said state Sen. Lois Wolk, D-Davis, who wrote California’s original POLST legislation, as well as the recent e-registry bill. “It was a 19th-century approach to have this 8-by-11 (-inch) form and put it on the door of your refrigerator in case of a medical emergency. That’s better than nothing, but that’s hardly ideal.”
Because the cost of creating a statewide database was prohibitive, Wolk’s bill only authorizes permission for an e-registry. She said outside funding is being sought to develop a pilot program through the state’s Emergency Medical Services Authority.
It’s hard to know exactly how many people have filled out a POLST form. In 2011, about 87 percent of California hospitals had POLST forms available to their patients, according to a recent report to the Coalition for Compassionate Care of California, which coordinates the state’s POLST program. According to a 2010 survey, nearly 54 percent of California nursing home residents had a POLST.
A POLST form enables individuals, in a conversation with a medical professional, to decide such questions as: If I stop breathing, do I want CPR and other efforts at resuscitation? If I can no longer swallow, do I want a feeding tube and for how long?
They can also select among three medical interventions: full treatment, selected treatment or comfort-focused treatment. The middle choice, for instance, indicates it’s OK for medical personnel to deliver IV fluids and antibiotics but the individual wants no intubation and to “generally avoid intensive care.”
These conversations can take place during a routine doctor’s office visit or in the hospital or other medical setting.
Wolk, who also co-wrote California’s recent end-of-life bill, said people are becoming more comfortable talking about their desires for how they want to leave this world.
“People are much more receptive to this. It reflects that our demographics are changing, our population is aging,” she said. “Medical technology has increased our ability to live longer, but not necessarily in the best quality of life.”
By allowing patients to choose exactly which medical interventions they want – or don’t want – it offers them some degree of control at the end of life, she said.
“Anyone can have a POLST form from the youngest baby to the oldest senior,” said Judy Thomas, CEO of the Coalition for Compassionate Care of California, which coordinates the state’s POLST program. For children, it’s usually those who may have a chronic condition or serious illness that’s not curable. In some cases, she said, disabled people want a POLST form to ensure that they’re not discriminated against in an emergency setting.
Overall, Thomas said, the form is “agnostic” whether someone wants every treatment possible or none at all. “It’s always voluntary for patients, but once somebody has a form, it’s mandatory that health care professionals honor it.”
Because it’s a physician’s order, valid throughout California, some medical professionals recommend taking a copy when on a trip, in case of an emergency. “Bring it with you when you travel,” said UC Davis Medical Center palliative-care nurse manager Eric Moore, “because you never know.”
Health systems such as Dignity Health offer classes covering POLST forms. But it’s not enough to just fill out a form and file it somewhere, said nurse practitioner Joanne Hatchett, who helps teach POLST classes at Dignity Health’s medical clinic in Woodland.
It’s also important to discuss your wishes with family members, she said.
“It matters when a patient loses capacity and the family doesn’t understand what the patient wanted,” said Hatchett. “They’re being asked to make decisions on mom’s behalf. When (adult siblings) don’t understand or agree, it makes for conflict within a family.”
Blickle’s husband, who battled health issues, wanted no CPR or medical intervention. Whisked to the hospital by paramedics, he died peacefully within hours of a cerebral aneurysm, his widow said.
Now 83, Blickle said she’s discussed her own wishes with her two grown children so that “we’re all on the same page.” Her POLST form is affixed with colorful magnets to her refrigerator, inside a zip-close bag that also contains a list of her medications, which her daughter suggested might be helpful in an emergency.
Blickle said her choices for life-saving treatment are somewhat different than her husband’s were. “For me, it’s peace of mind, knowing that everything will be done according to my wishes.”
What’s a POLST?
What it does: Officially called Physician Orders for Life-Sustaining Treatment, it’s a paper document that spells out exactly what you want done – or not – in the event of a medical emergency. Signed by patients and a medical professional, it directs emergency responders and others in how to handle treatment.
Who it’s for: Medically frail or seriously ill people, including children, who are under a doctor’s care and may not live another year. It’s not the same as an advance care directive, which names someone to handle health care decisions if you become incapacitated. Advance directives are recommended for all adults, regardless of medical condition; a POLST is typically only for those who have serious or chronic conditions.
Where it’s kept: In California, it’s typically printed on bright pink paper and stays with the person. Ideally, it should be kept in a prominent spot at home. If checking into a hospital, it should go with you.
What’s new: As of Jan. 1, California allows nurse practitioners and physician assistants to sign POLST forms. Also, lawmakers authorized a pilot program to create a statewide electronic registry of POLST forms so they’re easily accessible by emergency responders.
Where: POLST forms are offered in every state except five (Alabama, Alaska, Arkansas, Nebraska and South Dakota). In California, they can be downloaded in 12 languages at CaPOLST.org.
Classes: Some health systems offer free classes, open to the public, on POLST and advance care directives. Dignity Health offers classes on April 13, Sept. 14 and Nov. 16 at 10:30 a.m., 1700 Tribute Road, Sacramento (call 916-733-6330) or the first Tuesday monthly at Dignity’s Woodland clinic (530-669-5443). The UC Davis Health System offers “Honoring Your Health Care Decisions” classes every other month (next is Feb. 17) at varied locations. Call 916-734-0718 or send email to: firstname.lastname@example.org