Progressing living wills (advance directives): POLST

Living wills have come a long way since they were first proposed by Luis Kutner in 1969. Today they are widespread. On July 28th 2009, Barack Obama became the first United States President to announce publicly that he had a living will. But there are still problems with them, and many studies suggesting that similar treatment/non-treatment decisions would have been taken even in the absence of a living will. But a large scale study just published in America suggests a further level of directive can make some significant differences.

Researchers studied 1,711 nursing home residents aged 65 and older, looking at treatment preferences and decisions, and quantified the results both with traditional documents and with the addition of a POLST form. A POLST form (Physician Orders for Life-Sustaining Treatments) is a way of translating patients’ wishes about a range of treatments into medical orders that are easily understood by healthcare professionals in a way that can be acted upon immediately. Some people have compared it to a doctor writing a prescription as opposed to the patient describing the sort of medicine they want.

Residents with POLST forms were more likely to have treatment preferences documented as medical orders than residents with traditional practices (living wills, DNAR forms); and POLST orders restricting medical interventions were associated with the lower use of life-sustaining treatments such as hospitalization, intravenous fluids and antibiotics. There were no differences between residents with and without POLST forms in symptom assessment or management.

The POLST form is not a replacement for a living will. But it can in some cases take the values described in a living will and solidify them into hard and fast medical instructions, from doctors, to doctors.

Although it is too early to see if POLST documents will evolve in Britain (beyond the current DNAR – Do Not Attempt Resuscitation – forms). But a number of physical features indicate some simple measures that could even improve living wills.

The POLST is printed on bright pink paper to stand out from other medical documents. Exit feels this is important and for similar reasons our Living Will form is printed on thicker, eye-catching coloured paper. The layout is admirably simple and, rather like current DNAR forms, has strong lettering instructing: “Send Form With Person Whenever Transferred or Discharged.” Three principal categories cover a) Cardio-pulmonary resuscitation, b) Medical interventions ranging from ‘comfort measures only’ to intubation and ventilation, and c) Artificially administered nutrition.

But although POLST forms are not uncommon in several states in the U.S., further studies would be needed to discover their applicability in the U.K. environment. Neither are they perfect, and some of the criticisms applied to living wills, including the potential for abuse, can also be levelled at POLST forms.

Resources
The POLST form (sample)
The JAGS study on the uses of POLST (A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician
Orders for Life-Sustaining Treatment Program, Journal of the American Geriatrics Society vol58, no7)
Critical examination of POLST (A Critical Look at the Physician Orders for Life- Sustaining Treatment (POLST): What Are Its Weaknesses?)
Advance Directives Evolve to Ensure Better End-of-Life Planning (short article on advantages of POLST)
POLST California (homepage)
How to make a living will (DirectGov article – England & Wales)
The ethical factors surrounding living wills, also called active declarations (straightforward BBC page on making a living will)

There were no differences
between residents with and without POLST forms in symptom
assessment or management.
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