Lancaster Physician Spring 2017 - 27

SPRING 2017

POLST

to help delineate a person's wishes regarding
their health care.
CODE STATUS- In the event of a full
cardiac arrest that occurs in the context of
a life-threatening medical condition, would
you like the health care providers to attempt
cardio-pulmonary resuscitation (CPR)? Or
if a health condition becomes so severe that
your heart stops, should death be allowed to
occur in a natural way?
MEDICAL INTERVENTIONS- In the
event of a serious health condition that warrants hospitalization, how aggressive would
you like to be medically treated? There are
three options to choose: 1) Comfort measures
only. This means that hospital transfer would
only occur if comfort could not be achieved
in your current environment. 2) Limited
interventions. It would be OK to be in the
hospital with some IV medications, fluids and
basic testing, but you would not want overly
aggressive or "heroic" interventions. 3) Full
treatment. You want no medical treatment
withheld in the case of an emergency, including intubation, life support, and Intensive
Care Unit level of care.
ANTIBIOTICS- How aggressively would
you like your health care providers to use antibiotics in attempts to treat your condition?
ARTIFICIAL FEEDING AND HYDRATION- If you became so critically ill that
you could not eat or drink on your own,
would you want your health care providers
to insert a tube in your vein, nose, or stomach to provide nutrition? Is this a treatment
you would be OK with for a long time, or
something you would only want to consider
for a short period of time?
It is most helpful to use a context that is
familiar and easy to understand, such as pneumonia. "If you were to contract pneumonia
and your condition was worsening, would you
be comfortable going to the hospital for more
aggressive treatment? What if your lungs got
so bad that you needed to be intubated and
placed on a ventilator for a period of time?
Would you be open to that? What if the
infection got so bad and your blood pressure
so low that your heart stopped? Would you

want the people in the hospital to perform
chest compressions, shock your heart, and
intubate you to try and restart your heart?
While the hospital was treating your illness,
would you be open to a trial of artificial
feeding with a tube? If it looked like your
condition was not improving, would you
want to continue the antibiotics?"
POLSTs, like living wills, are not meant
to be all-inclusive orders that cover every
possible medical scenario. Medical treatment
options are too vast and complex to be covered
in a single document. It is not meant to be
overwhelming or to capture with certainty
every possible medical decision. Nor is it
meant to be set in stone (unlike a living will,
a POLST can be changed at any time) or to
replace patient (or surrogate) autonomy in
their health care decisions. What the POLST
is meant to do is initiate a guided conversation
between a trusted health care provider and
their patient about what is important to that
person today, knowing what they know about
their health and prognosis. It is meant to allow
a provider to understand what is important to
their patient, and what gives "quality of life"
to that patient. It can serve as a tool to allow
open discussions about life expectancy and
benefits vs. harms of various medical diagnosis
and treatment options. Most importantly,

LANCASTER

27

PHYSICIAN

it allows providers to assess what a person's
goals for their health care treatment are and
to assess how realistically those goals can be
met. With these four questions, a provider
can give a framework and context for all other
medical decisions from that point forward.
It allows clearer understanding and better
communication by both the provider and the
patient. By knowing a patient's preferences
and expectations, a provider can determine
and explain how those goals can be met
within the current health care environment.
To be effectively used, the POLST document must be readily available during a
change in health. The completed POLST
should be shared with family, POA, PCP
and anyone who may be involved in future
decisions. Many people post it on their
refrigerators, in a "vial of life," or with other
easily found legal documents. The presence
and details of the POLST should be noted
in the patient progress note, on the patient
problem list, and scanned into a searchable
location on the EMR.



Table of Contents for the Digital Edition of Lancaster Physician Spring 2017

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