Effective October 1, California has updated its Physician Orders for Life-Sustaining Treatment (“POLST”) form, the document that physicians can use to record a person’s wishes regarding the provision of life sustaining treatment for use in the event of future incapacity. The updating was done by the Coalition for Compassionate Care of California and approved by the California Emergency Medical Services Authority. Health care providers in California should be aware of the updates and should look to use the new form immediately.

A POLST is a means of representing a person’s wishes for his or her care in the event of incapacity or inability to communicate. It is completed by a physician in consultation with either the patient or a legally appointed decision maker who can convey the patient’s wishes, and is considered to be a physician order. It is intended to communicate the extent of life-sustaining treatment that the patient wishes to receive, and to prevent unwanted interventions. It addresses the provision of cardiopulmonary resuscitation (CPR) if the patient is found with no pulse or breathing (Section A), the degree of medical intervention if the patient is found with a pulse or still breathing (Section B), and the patient’s preferences regarding artificially administered nutrition (Section C).

While it looks nearly identical to its predecessor, the updated POLST form has several features that are intended to make it easier to understand and to permit the patient’s care plan to evolve over time. The most important changes appear in Section B, which lists options for medical intervention if the patient is found with a pulse or still breathing. The previous version listed “Comfort Measures Only,” “Limited Additional Interventions,” and “Full Treatment” as options, in that order. The update has reordered and renamed the options, which are now “Full Treatment,” “Selective Treatment,” and “Comfort-Focused Treatment.” “Selective Treatment” has replaced the previous “Limited Additional Interventions” label, and “Comfort-Focused Treatment” has replaced the “Comfort Measures Only” label. The definitions of each option, however, have not changed.

Most significantly, the updated form includes a new option: Under “Full Treatment,” the person may select a “Trial Period of Full Treatment.” This suggests that a person may wish to have short-term ventilator support, for example, but not prolonged life support. Because the POLST form requires that a person request the “Full Treatment” option if he or she also selects “Attempt Resuscitation/CPR,” the “Trial Period of Full Treatment” option may be used for those who desire CPR and short-term ventilator treatment, but who also want the ventilator treatment to be withdrawn if long-term life support would be required.

The Coalition for Compassionate Care of California has provided informal guidance regarding use of the form. According to it, POLST orders using the previous form will continue to be valid after October 1, whether signed before or after that date. The Coalition recommends, however, that the new form be used where a POLST is being completed for the first time and that it replace the old form for persons with existing POLSTs wherever possible. To avoid confusion, the old form should be voided any time that the updated one is signed.

A provider must honor a completed POLST form, although it can be modified or revoked at any time either verbally or in writing. Providers should remember that a POLST form is not mandatory, and that an Advance Health Care Directive or a Pre-hospital Do Not Resuscitate (“DNR”) form may complement it or stand in its place. The most recently dated document is considered to be controlling. If a person wishes to have both a POLST and another form, a provider should check to make certain that they are consistent with one another.

Providers billing to Medicare or Medi-Cal should also be aware that Section S of the Minimum Data Set ("MDS") has been updated concurrently with the POLST form. Effective October 1, the response codes for treatment options selected on a POLST form are reordered and renamed in the same fashion as the updated form.

Copies of the updated POLST form may be downloaded from www.caPOLST.org or purchased from MedPass at http://med-pass.com. While the form will be honored on any color paper, it is recommended that the form be copied or printed on 65# Ultra Pink card stock to distinguish it from other medical forms and to make it easily identifiable by the providers who may be called upon to honor it.