Integrating POLST into Palliative Care Guidelines: A Paradigm Shift in Advance Care Planning in Oncology

Because predicting and outlining guidance for all possible scenarios is difficult, advance directives are rarely sufficiently precise to dictate patient preferences in specific situations as a disease progresses. Nonetheless, advance care planning is an essential process that should begin at the time of diagnosis, if not already initiated, to ensure that all patient and family rights are preserved. Communicating effectively with the patient and family and having the patient designate a surrogate decision-maker are critical. Attention must be paid to resolving conflicts among patient values and preferences and those of family and the health care team. Patient-centered goals for care and expectations should be elicited at first assessment and reassessed frequently as conditions change. As a disease progresses, advance directives are rarely precise enough to predict all possible scenarios and outline guidance for care. Therefore, for patients with advanced metastatic cancer and a potential life expectancy of less than 1 year, converting patient-centered treatment goals into actionable medical orders while the patient maintains capacity is a more effective way to ensure that patient preferences are honored. Physician Orders for Life-Sustaining Treatment (POLST) and similar medical order forms provide explicit direction about resuscitation status (“code status”) if the patient is pulseless and apneic. POLST also includes directions about additional interventions the patient may or may not want. A decade of research in Oregon has proved that the POLST Paradigm Program more accurately conveys end-of-life preferences that are more likely to be followed by medical professionals than traditional advance directives alone.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Correspondence: Patricia A. Bomba, MD, Geriatrics, Excellus BlueCross BlueShield, 165 Court Street, Rochester, NY 14647. E-mail: Patricia.Bomba@lifethc.com
  • 1.

    Cancer Trends Progress Report—2005 Update. Bethesda, MD: National Cancer Institute. Available at: http://progressreport.cancer.gov/survival-estimation-methods.asp. Accessed July 1, 2006.

    • Search Google Scholar
    • Export Citation
  • 2.

    Levy MH, Back A, Bazargan S. The NCCN Palliative Care Clinical Practice Guidelines in Oncology™, version 2.2005. Jenkinstown, PA: National Comprehensive Cancer Network. Available at: http://www.nccn.org/professionals/physician_gls/PDF/palliative.pdf. Accessed July 1, 2006.

    • Search Google Scholar
    • Export Citation
  • 3.

    The Center for the Evaluative Clinical Sciences, Dartmouth Medical School. The quality of medical care in the United States: a report on the Medicare program. In: The Dartmouth Atlas of Health Care 1999. Chicago, IL: Health Forum, Inc.; 1999.

    • Search Google Scholar
    • Export Citation
  • 4.

    Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients' perspective. JAMA 1999;281:163168.

  • 5.

    McGraw SA, Dobihal E, Baggish R. How can we improve care at the end of life in Connecticut? Recommendations from focus groups. Conn Med 2002;66:655664.

    • Search Google Scholar
    • Export Citation
  • 6.

    Ott BB. Advance directives: the emerging body of research. Am J Crit Care 1999;8:514519.

  • 7.

    Dexter PR, Wolinsky FD, Gramelspacher GP. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms. Ann Intern Med 1998;128:102110.

    • Search Google Scholar
    • Export Citation
  • 8.

    Wenger NS, Kanouse DE, Collins RL. End-of-life discussions and preferences among persons with HIV. JAMA 2001;285:28802887.

  • 9.

    Emanuel LL, Barry MJ, Stoeckle JD. Advance directives for medical care—a case for greater use. N Engl J Med 1991;324:889895.

  • 10.

    Gordon NP, Shade SB. Advance directives are more likely among seniors asked about end-of-life care preferences. Arch Intern Med 1999;159:701704.

    • Search Google Scholar
    • Export Citation
  • 11.

    Hahn ME. MSJAMA. Advance directives and patient-physician communication. JAMA 2003;289:96.

  • 12.

    Morrison RS, Meier DE. High rates of advance care planning in New York City's elderly population. Arch Intern Med 2004;164:24212426.

  • 13.

    Partnership for Caring. Gallup poll results, ``Facts about End-of-Life Care.'' Princeton, NJ: Robert Wood Johnson Foundation. Available at: http://www.partnershipforcaring.org. Accessed July 1, 2006.

    • Search Google Scholar
    • Export Citation
  • 14.

    Robert Wood Johnson Foundation. Means to a better end: a report on dying in America today. Princeton, NJ: RWJF. Available at: http://www.rwjf.org/files/publications/other/meansbetterend.pdf. Accessed July 1, 2006.

    • Search Google Scholar
    • Export Citation
  • 15.

    The PEW Research Center for the People and the Press. Strong public support. More Americans discussing—and planning—end-of-life treatment. January 5, 2006. Available at: http://people-press.org/reports/display.php3?ReportID=266. Accessed July 12, 2006.

    • Search Google Scholar
    • Export Citation
  • 16.

    Tierney WM, Dexter PR, Gramelspacher GP. The effect of discussions about advance directives on patients' satisfaction with primary care. J Gen Intern Med 2001;16:3240.

    • Search Google Scholar
    • Export Citation
  • 17.

    Singer PA, Martin DK, Lavery JV. Reconceptualizing advance care planning from the patient's perspective. Arch Intern Med 1998;158:879884.

  • 18.

    Schwartz CE, Wheeler HB, Hammes B. Early intervention in planning end-of-life care with ambulatory geriatric patients: results of a pilot trial. Arch Intern Med 2002;162:16111618.

    • Search Google Scholar
    • Export Citation
  • 19.

    Tilden VP, Tolle SW, Nelson CA, Fields J. Family decision-making to withdraw life-sustaining treatments from hospitalized patients. Nurs Res 2001;50:105115.

    • Search Google Scholar
    • Export Citation
  • 20.

    Prochaska J, DiClemente C. The Transtheoretical approach: crossing traditional boundaries of therapy. Homewood (IL): Dow Jones-Irwin, 1984.

    • Search Google Scholar
    • Export Citation
  • 21.

    Prochaska JO, DiClemente CC. Common processes of self-change in smoking, weight control, and psychological distress. In: Shiffman S, Wills T, eds. Coping and Substance Abuse: A Conceptual Framework. New York: Academic Press, 1985:345363.

    • Search Google Scholar
    • Export Citation
  • 22.

    Prochaska JO, Goldstein MG. Process of smoking cessation. Implications for clinicians. Clin Chest Med 1991;12:727735.

  • 23.

    Bomba PA. Advance care planning along the continuum. Case Manager 2005;16:6872.

  • 24.

    Covinsky KE, Fuller JD, Yaffe K. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc 2000;48(5 suppl):S187S193.

    • Search Google Scholar
    • Export Citation
  • 25.

    Fischer GS, Arnold RM, Tulsky JA. Talking to the older adult about advance directives. Clin Geriatr Med 2000;16:239254.

  • 26.

    Balducci L, Cohen HJ, Engstrom PF. The NCCN Senior Adult Oncology Practice Guidelines in Oncology™, version 1.2005. Jenkinstown, PA: National Comprehensive Cancer Network. Available at: http://www.nccn.org/professionals/physician_gls/PDF/senior.pdf. Accessed July 1, 2006.

    • Search Google Scholar
    • Export Citation
  • 27.

    Miller DL, Bolla LR. Patient values: the guide to medical decision making. Clin Geriatr Med 1998;14:813829.

  • 28.

    Lang F, Quill T. Making decisions with families at the end of life. Am Fam Physician 2004;70:719723.

  • 29.

    Miller DL, Gorbien MJ, Simbartl LA, Jahnigen DW. Factors influencing physicians in recommending in-hospital cardiopulmonary resuscitation. Arch Intern Med 1993;153:19992003.

    • Search Google Scholar
    • Export Citation
  • 30.

    Zoch TW, Desbiens NA, DeStefano F. Short- and long-term survival after cardiopulmonary resuscitation. Arch Intern Med 2000;160:19691973.

  • 31.

    Rabinstein AA, McClelland RL, Wijdicks EF. Cardiopulmonary resuscitation in critically ill neurologic-neurosurgical patients. Mayo Clin Proc 2004;79:13911395.

    • Search Google Scholar
    • Export Citation
  • 32.

    Tulsky JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients? J Gen Intern Med 1995;10:436442.

  • 33.

    Fischer GS, Tulsky JA, Rose MR. Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med 1998;13:447454.

    • Search Google Scholar
    • Export Citation
  • 34.

    Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television: miracles and misinformation. N Engl J Med 1996:334:15781582.

  • 35.

    Murphy DJ, Burrows D, Santilli S. The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994;330:545549.

    • Search Google Scholar
    • Export Citation
  • 36.

    Morrison RS, Meier DE. Palliative care. N Engl J Med 2004;350:25822590.

  • 37.

    Miles SM, Koepp R, Weber EP. Advance end-of-life treatment planning: a research review. Arch Intern Med 1996;156:10621069.

  • 38.

    Oregon Health & Science University. Physician Orders for Life-Sustaining Treatment Program. 2005. Portland, OR: OHSU. Available at: http://www.ohsu.edu/ethics/polst/index.shtml. Accessed July 1, 2006.

    • Search Google Scholar
    • Export Citation
  • 39.

    Lee MA, Brummel-Smith K, Meyer J. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly. J Am Geriatr Soc 2000;48:12191225.

    • Search Google Scholar
    • Export Citation
  • 40.

    Meyers JL, Moore C, McGrory A. Physician orders for life-sustaining treatment form: honoring end-of-life directives for nursing home residents. J Gerontol Nurs 2004;30:3746.

    • Search Google Scholar
    • Export Citation
  • 41.

    Schmidt TA, Hickman SE, Tolle S, Brooks HS. The Physician Orders for Life-Sustaining Treatment program: Oregon emergency medical technicians' practical experiences and attitudes. J Am Geriatr Soc 2004;52:14301434.

    • Search Google Scholar
    • Export Citation
  • 42.

    Hickman SE, Tolle SW, Brummel-Smith K, Carley MM. Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status. J Am Geriatr Soc 2004;52:14241429.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 164 128 10
PDF Downloads 94 82 5
EPUB Downloads 0 0 0