Thursday, September 10, 2009

So What's a POLST Form?

A patient I'll call Mary had terminal cancer and had completed her advance directive and had her daughter as her Power of Attorney for Health Care. She didn't want to be resuscitated if her breathing or heart stopped. Hospice was to visit her later in the week, likely to get her enrolled. A wrist band was available in those years saying "DNR" but Mary didn't know about it yet.

A neighbor friend was able to stay with Mary to allow her daughter out for a while to do some shopping and to get her hair done. The neighbor really loved Mary but didn't know what to do when Mary suddenly stopped breathing and slumped over. So 911 was called and within 3 minutes the Medic One team arrived full tilt. They couldn't get medical information from the neighbor other than, "I think she has a bad cancer."

Medic One is trained to rapidly assess and treat unless it's very clear not to intervene. Thus they rapidly diagnosed ventricular fibrillation, started CPR and applied cardioversion electrical shocks. The daughter arrived on the scene and screamed at them that her mother was dying and didn't want this. By this time, the heart had restarted and an endotracheal tube was in place. Mary was unconscious and taken to the ER at the hospital when I was on call.

The ER doc called me and said, "Jim, this is a bad situation. We have the documentation now from the daughter that the patient didn't want CPR and she's mad at Medics who were only doing their job." There were no other family members and the daughter had decision authority. The medical records were quickly reviewed (all electronic) so we had the confirmatory notes from her oncologist. There was no doubt she was terminal. Mary was allowed to die in the ER. All involved were saddened by how "the system" had failed.

In subsequent years, the POLST (Physician Orders for Life Sustaining Treatment) was implemented in Washington State. It's also in California, Oregon and a few eastern states and under development in a number of others. Basically this form takes your wishes, puts them into specific medical orders, and it is signed by you (or your surrogate) and your medical provider. The form is large, bright colored and easy to spot on a bedroom door. It can say treat or don't treat taking on such things as CPR, fluids, nutrition, palliative pain management, etc. The beauty of this form is that it is patient centered, not institution centered. It is thus honored by Emergency Rooms, Medic One, Hospitals, and Nursing Facilities.

The POLST form is really for the seriously ill or very elderly who are sure what they would or wouldn't want in terms of medical intervention. It's certainly appropriate for all Hospice patients. One lady told me that she had three of these forms posted up around her house. This 88 year old woman said, "I don't want some stranger pounding on my chest when I die."

For more information about the POLST form, please see


  1. Thanks for covering these issues and in a compelling, first person perspective sort of way, that I cannot. I have added this blog to my related links at

  2. As a person who teaches the law of trusts and estates, I find myself needing each year to talk about the legal side of physicians' directives, durable powers of attorney, and so forth. It is very helpful to have you give your first person perspective on how these things look from a doctor's point of view and, from what they tell you, the patient's. Thanks so much.