OkPOLST stands for Oklahoma Physician Orders for Life-Sustaining Treatment. It refers to a physician’s order that documents and directs a patient’s medical treatment preferences when faced with life-limiting illnesses and irreversible conditions. The form represents a model program for end-of-life care.
The mission of OkPOLST is to improve end-of-life care in Oklahoma by creating documents and programs that promote honoring the health care wishes and goals of care of those with life-limiting and irreversible conditions.
The OkPOLST form represents the wishes and goals of care of the patient, and is translated into a physician’s order that is readily available to other health care providers that may be involved in the patient’s care. The information in the OkPOLST form is obtained from a conversation between the patient or his/her legal health care representative and his/her physician. Studies conducted in states that have similar documents available have revealed that among patients who have those documents, treatment preferences were honored 98 percent of the time, and no one received unwanted intubation, CPR, intensive care or feeding tubes. As a result, documents like the OkPOLST form have helped bridge the gap between what treatments the patient wants and what the patient receives.
Cultural and religious beliefs vary widely in regard to end-of-life care. There are many resources available to help patients determine if the OkPOLST form is right for them, based on their personal beliefs. Patients are also encouraged to discuss the form with their clergy or religious or spiritual leaders.
No. The OkPOLST form is recommended as the standard of care to be used by Oklahoma health care providers to document a physician’s orders directing a patient’s medical treatment preferences when facing life-limiting and irreversible conditions. It has the same legal standing as other physician’s orders.
No. An advance directive, also known as a ‘living will,’ is a legal document that provides instructions specifying what types of treatment should be given to a person when that person becomes unable to make decisions or can no longer speak for him/herself. It only goes into effect if the patient loses the ability to make decisions. An advance directive can be very specific or very vague.
The OkPOLST form, however, is used as part of the health care planning process and is complementary with advance directives. It may also be used in the absence of an advance directive. In addition, the OkPOLST form is a physician’s order that specifically outlines a patient’s medical treatment wishes and goals of care. As a physician’s order, it should be honored by all health care professionals, and it can be used to translate an advance directive into a physician’s order. Also, because the OkPOLST form becomes part of the patient’s medical record, it travels with the patient across health care settings. For reference purposes, those with questions about the difference between advance directives and the OkPOLST form may find the following table helpful:
|For anybody age 18 and older||For persons with advanced life-limiting illness and irreversible conditions at any age.|
|Provides instructions for future treatment||Provides medical orders for current treatment|
|Appoints a healthcare proxy||Does NOT appoint a healthcare proxy|
|Guides treatment decisions when available and the patient is incapacitated||Guides treatment decisions when available. Does not require incapacitation or "activation"|
|Cannot be signed by a legal healthcare representative on behalf of an incapacitated person.||
Can be signed by a patient with capacity or if incapacitated, by the patient’s legal health care representative.
Yes. The form is designed to become part of the patient’s medical record. It transfers with the patient across health settings, from home to hospital to long-term care facility or hospice care. When the patient transfers to a new health setting, the patient’s original OkPOLST form should accompany him/her. In addition, a copy of the patient’s OkPOLST form should be kept in the patient’s medical record.
The OkPOLST form is a standardized form that is printed on pink paper to ensure that it is easily identified by patients, their loved ones and their health care providers.
The OkPOLST form can be copied. Photocopies and faxed copies of signed OkPOLST forms are considered valid. It is recommended that the copies be made on pink paper whenever possible to ensure that the form is easily identified. The copy must include the patient’s most recent wishes. Patients are encouraged to keep copies of their OkPOLST forms in their possession and to let their families and/or physicians know where the form is kept in case it is needed.
No. The OkPOLST form is not biased for or against treatment. It is non-judgmental, and it provides patients with the opportunity to choose and clearly state their own preferences for medical treatment when faced with a life-limiting and/or irreversible condition.
The OkPOLST form must be signed by the patient AND the patient’s physician to become valid. If the patient lacks decision-making capacity, the form may be signed by the patient’s legal health care representative. Oklahoma statutes identify the legal health care representative to be a Health care Proxy named in a Health care Advance Directive, an Attorneys-in-Fact named in a health care Durable Power of Attorney or a Guardian.
The physician must be licensed to practice medicine in Oklahoma, but he/she is not required to be on the medical staff at the patient’s treating facility.
There is currently no process for validating the license numbers on the OkPOLST form, but contact information for the signing physician must be provided. As Oklahoma’s physicians and health care facilities transition to electronic health records and a state-wide electronic health information exchange, this will become less of an issue.
Yes. Physicians should honor the orders stated in the patient’s OkPOLST form immediately, but the patient’s physician is obliged to examine, assess and review the orders any time the patient transfers to a new health care setting, as health status and goals of care may have changed. The physician may then issue new orders consistent with the most current information about the patient’s health status, medical condition, treatment preferences and goals of care. Any deviations from the patient’s original OkPOLST form will be documented and dated on the second page of the OKPOLST form where space is provided for numerous order changes. The changes should also be documented in the patient’s medical record.
No. In some cases, physicians have been hesitant to follow OkPOLST orders without first reassessing the patient’s wishes in his/her current clinical situation. However, the OkPOLST should be followed until a review is completed by the accepting health care professional. The OkPOLST form should be followed even if the physician who signed the form is not on the medical staff of the patient’s treating facility.
To date, there has been only one case filed in California and that case concerns an Emergency Room physician who did not honor the POLST form. This form has been used in many states since 1994 and has the ability to honor patient’s wishes across care settings. Currently, there are only seven states without a POLST program in any form of development: Alabama, Arkansas, Mississippi, Nebraska, South Dakota, Texas and Washington, D.C. There are 28 states in the process of developing POLST programs. The POLST forms used by each state are similar in that they are designed for use only by patients with serious advanced illnesses whose current health status indicates the need for standing medical orders.
Discussing the plan of care is fundamental to all physician/patient relationships and is integral to medical care. In October, 2015, the Centers for Medicare and Medicaid Services (CMS) approved specific reimbursement for physicians to counsel their patients on end of life care preferences. Discussing and completing an OkPOLST form would be part of this reimbursed counseling.
In 2011, the federal government set a goal that all Americans would have electronic health records (EHRs) by 2014. Because OkPOLST is a physician order, it would be included in a patient’s EHR. The OkPOLST Task Force is working with local health care information exchanges to create a state-wide registry. The registry will be a secure, confidential network that allows authorized providers to access a patient’s EHR for the purpose of improving patient safety, quality of care and health outcomes.
The OkPOLST form is most useful for patients who are seriously ill with life-limiting and irreversible illnesses and whose life expectancy is less than one year or who are frail and elderly. It can be completed for any patient regardless of age.
Under Oklahoma law, a guardian does not have the power to consent on behalf of the ward to withhold or withdraw life-sustaining procedures except with specific court authorization or as authorized by an advance directive executed pursuant to state law.
If the patient or the patient’s legal health care representative wishes to complete an OkPOLST form, the patient’s physician should be contacted. The physician should discuss treatment options including information about the patient’s advance directive (if any) or other statements the patient has made regarding his/her wishes for end-of-life care and treatments. The benefits, burdens, efficacy and appropriateness of treatment and medical interventions should be discussed by the physician with the patient and/or the patient’s legal health care representative.
Another member of the health care team such as a nurse or social worker may explain the OkPOLST form to the patient and/or the patient’s legal health care representative, however, the physician is responsible for discussing treatment options with the patient or the patient’s legal health care representative.
Opening the conversation may sound something like this: “I’d like to talk with you today about what is going on with you which will help me understand how to best care for you or your family member. We will need to discuss the types of treatments available, what will work, what might work, and what will not work and what your goals of care are. After we have this discussion, we will be able to complete an OkPOLST form which is a physician’s order that outlines the plan of care we discussed. This order will communicate this important information to other members of the health care team so they know how to best care for you during your illness. This form will transfer with you across care settings. The OkPOLST form can be changed or adjusted at any time as long as it is represents your wishes and goals of care.”
Opening the conversation may sound something like this: “I’d like to talk with you about your illness and learn more about what your personal goals of care are and what types of treatment you want and don’t want. It is important for me to understand your wishes so that I can help to make sure those wishes are honored as your illness progresses or if you become unable to speak for yourself. After we discuss your wishes, we can use the OkPOLST form to record them so that we’ll have a physician’s order that will travel with you across health care settings. This form will ensure that your wishes are honored, and we can adjust it any time to reflect any changes in your wishes or condition.”
Opening the conversation may sound something like this: “I’d like to discuss my condition with you and share with you my goals of care. There are some treatments I do want and others that I don’t want, and I’d like you to know what those are so there is no confusion later. It is also important to me that we discuss my personal and religious beliefs that affect my wishes for treatment. After we have this discussion, I would like to record my wishes in an OkPOLST form, which will help to ensure that my wishes are honored as my condition progresses or if I become unable to speak for myself.”
A health care durable power of attorney authorizes someone else (called an ‘attorney-in-fact’ or ‘agent’) to make decisions on behalf of the patient when the patient is no longer able to make decisions or speak for him/herself. The agent may only perform the tasks or make the decisions specifically authorized in the health care durable power of attorney document.
An advance directive is not required to complete the OkPOLST form, but it can complement the OkPOLST form. When the patient is no longer able to make his/her own decisions, the OkPOLST form may be completed by a patient’s proxy named in an advance directive or by an attorney-in-fact named in a health care durable power of attorney or a guardian subject to the limitations placed on guardians under Oklahoma law.
In cases in which the patient’s advance directive states different wishes than an OkPOLST form, the most recent expression of the patient’s wishes is honored. The patient will receive life-sustaining medical treatment until additional information or clarification resolves the conflict. Ultimately, it is the responsibility of the attending physician to clarify any conflicts between the two documents.
a. If the OkPOLST conflicts with the patient’s previously-expressed health care instructions or advance directive, then, to the extent of the conflict, the most recent expression of the patient’s wishes are honored.
b. If there are any conflicts or ethical concerns about the OkPOLST orders, appropriate hospital or health care facility resources – e.g., ethics committees, care conference, legal, risk management or other administrative and medical staff resources – may be utilized to resolve the conflict.
c. During conflict resolution, consideration should always be given to:
1) the attending physician’s assessment of the patient’s current health status and the medical indications for care or treatment;
2) the determination by the physician as to whether the care or treatment specified by OkPOLST is medically ineffective, non-beneficial, or contrary to generally accepted health care standards; and
3) the patient’s most recently expressed preferences for treatment and the patient’s treatment goals.
While all three forms are not required, it is recommended that patients with life-limiting and irreversible conditions have an advance directive that appoints a health care proxy or a health care durable power of attorney and an OkPOLST form directing a health care provider on his/her medical treatment preferences at the end of life.
The OkPOLST form should be reviewed when the patient is transferred from one health care setting to another; when the patient experiences a significant change in condition; and/or when the patient’s treatment preferences change. The form includes a section that records when and why the form was reviewed and whether any changes were made. The OkPOLST form is designed to be a living document and should always reflect the patient’s most recent wishes for medical treatment and goals of care.
Yes. The OkPOLST form addresses cardiopulmonary resuscitation, or CPR, in Section A. The orders specified in this section are applied only when the patient has no pulse and is not breathing, and do not apply to any other medical circumstances. If the patient wants CPR in this situation, those wishes are specified in this section, and full CPR measures will be performed. If the patient does not want CPR in this situation, he/she may choose the ‘Do Not Resuscitate’ option, which means CPR will not be performed and defibrillators will not be used. The patient should understand that comfort measures will always be provided if the ‘Do Not Resuscitate’ option is selected.
DNR stands for ‘Do Not Resuscitate.’ It means that no attempts will be made to restart the heart or breathing if the patient has no pulse or respiration.
Comfort measures only means the care and treatment provided will be for the purpose of enhancing comfort, controlling pain and symptoms and relieving the patient’s suffering. Positioning and wound care will be used to relieve the patient’s pain and suffering. The use of pain medication, oxygen, oral suction and manual treatment of airway obstruction will also be used as needed to ensure comfort. Measures such as Continuous Airway Pressure, or CPAP, which uses mild air pressure to keep the airways open, and Bilevel Positive Airway Pressure, or BiPAP, which is a breathing apparatus that helps the patient get more air into his/her lungs, may also be used to provide comfort.
Full treatment refers to all appropriate life-sustaining treatments and may include the use of intubation, advanced airway intervention, mechanical ventilation, cardioversion, transfer to hospital, and use of intensive care, as indicated. It also means that in medical emergencies, 911 is called.
Yes. The form includes a section that allows the patient to decide whether or not he/she wants nutrition and fluids by tube or IV. The form also allows the patient to state whether he/she would prefer a trial period, or if he/she wants long-term artificially administered nutrition and fluids.
Food and water are provided by mouth whenever possible. This is clearly indicated in bold print in Section D of the OkPOLST form. If a patient is no longer able to eat and drink because of an illness from which he/she is not expected to recover, then continued discussions need to occur about the burden versus the benefit of 'invasive' feeding by tube or IV versus comfort care. Comfort care would include keeping the mouth and lips moist and providing food and water by mouth as tolerated. In some cases, to persist in providing artificially administered nutrition and hydration may become unduly burdensome for the patient and is not medically indicated.
The OkPOLST form provides additional orders or comments to be added in sections B, C and D. The patient may use these sections to relay special instructions, whatever those instructions may be.
Additional information, including the POLST form, and information for consumers, health care professionals and health care organizations, is available on the OkPOLST website. A collaborative effort is underway to educate Oklahoma’s health care providers, caregivers, social workers, religious leaders/organizations, patients and consumers about the OkPOLST form.