POLST Toolkit

Welcome to the Washington POLST Clinician Toolkit

This toolkit is designed to assist health care teams identify who should be offered a POLST, how to apply clinical decision-making to know when and how to offer POLST, how to avoid pitfalls in the clinical use of POLST, and how to ensure a POLST reflects an individual’s goals. This toolkit contains resource materials to explain how to use a goals of care conversation in conjunction with POLST to provide whole-person care and ensure individuals with serious illness receive care that is consistent with their values and goals.

This toolkit was developed by Honoring Choices Pacific Northwest with the support and cooperation of the Washington POLST Task Force, the Washington End of Life Coalition, the Washington State Medical Association, and the Washington State Hospital Association.

For a video introduction to the toolkit, watch the WSMA Continuing Professional Development webinar, “The Washington POLST Clinician Toolkit: Best Practices to Ensure Person-Centered Care.” This activity has been approved for AMA PRA Category 1 Credit™.  Watch video and claim CME credit.

Please visit wsma.org/POLST to order the Washington POLST, find POLST brochure translations, and access additional webinars around the Washington POLST.

• What is POLST?

  The Washington state Portable Orders for Life Sustaining Treatment (POLST) is a set of portable, actionable medical orders designed to communicate an individual’s wishes regarding care in the event of an emergency, when they cannot speak for themselves. Emergency medical services can act on the decisions found in the POLST.

• What decisions are captured within POLST?

  POLST allows individuals, or their agents, to make decisions on:

  • Cardiopulmonary Resuscitation
  • Medical Interventions
    • Full Treatment
    • Selective Treatment
    • Comfort-Focused Treatment
• Who is the intended population for POLST?

  POLST is intended for individuals with serious life-limiting medical conditions or advanced frailty. Examples of medical conditions where a POLST should be considered (not an complete list):

  • Severe Heart Disease
  • Metastatic Cancer or Malignant Brain Tumor
  • Advanced Lung Disease
  • Advanced Renal Disease
  • Advanced Liver Disease
  • Advanced Frailty
  • Advanced Neurodegenerative Disease (e.g., Dementia, Parkinson’s Disease, ALS)

  POLST should be offered if you would not be surprised if the individual died in the next 1-2 years or if the individual would be potentially harmed by, or their overall condition worsened by, aggressive invasive measures, including cardiopulmonary resuscitation (CPR).

• How is POLST used?

  POLST is used to tell health care personnel, especially emergency medical services (EMS) providers and those working in out-of-hospital settings, what level of care the person would want in an emergency.

  The completed POLST is a portable medical order form; it should remain with the individual if they are transported between care settings, regardless of whether they are in the hospital, at home or in a long-term care facility. The institution may wish to keep a duplicated copy in the permanent medical record upon discharge.

• What makes a POLST valid?

  While POLST is not a legislated document, the legal resources that support POLST are found in the Revised Code of Washington (RCW) that directs emergency services. The RCW stipulates that for a POLST to be valid, it must have the following:

  • “…the person must SIGN A DIRECTIVE… requesting that they not receive [certain] emergency medical treatments.”
  • The guidelines include the need for a medical order to accompany this patient-signed directive
  • Signature of a qualified clinician, which includes Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Advanced Registered Nurse Practitioner (ARNP), Certified Physician’s Assistant: PA-C
• Does a POLST expire? When should it be updated?

  In Washington, the form does not expire. To maintain accuracy, a POLST should be reviewed when:

  • The individual is transferred from one care setting or care level to another,
  • There is substantial change in the individual’s health status
  • The individual’s treatment preferences change

  A review of the plan of care on the POLST should be documented in the Review Section on the back side of the POLST. If no changes are made, indicate the clinician who discussed the review (this does not have to be a signing clinician).

• Where should a POLST be stored?

  Since POLST orders should always be completed in the context of the medical encounter, the recommendation is that the health care team take responsibility for ensuring the POLST is properly stored and is retrievable when needed.

  The following are best practices for ensuring POLST can be found and honored:

  • Ensure each completed POLST is scanned into any and all electronic medical records.
  • Ideally, emergency medical services will have access to the electronic version of POLST or can quickly access the information on the POLST
  • Instruct the individual, or their health care agent as well as any responsible caregiver or family member, about how to store the original of the POLST. This includes:
    • Suggest place where the individuals lives where it can be quickly located
    • Make copies for any and all responsible/possible parties who may be called in the event of an emergency for the individual
  • Ensure that staff in every setting are trained to look for and honor the POLST orders.
• What if a section in a POLST is blank or missing?

  Any incomplete section of POLST implies full treatment for that section. Follow the directions on all completed sections.

  If a copy of a POLST only contains the front side, it is recommended to locate the original to ensure all the individual’s preferences and decisions are captured in the medical record.

• What if either the individual or the advanced practitioner/physician’s signature is missing?

  A POLST is invalid without both the signature of the individual and the signature of a physician or advanced practitioner (DO, ARNP, PA-C). The signature of the individual’s health care agent is accepted if the individual does not have capacity to sign on their own.

• Can a patient from another state have a WA POLST?

  Yes. An individual can have a POLST in more than one state. It is highly recommended that POLSTs from different state indicate the same preferences and decisions.

  If an individual has a POLST from another state it has to generally meet the requirement of the state in which the acting medical team practices; e.g., if someone has an Oregon POLST and wants it to be valid in Washington then the individual has to sign it.

• Can an advanced practitioner or physician sign a POLST for another state?

  Yes. A provider (MD, DO, ARNP, PA-C) can sign a POLST from a state other than where they practice. POLST is generally honored across state lines, but physician licensing is by state. Providers should check their licensure for any interstate considerations.

• What is a legal medical decision-maker?

  If you cannot make your own health care decisions, your legal medical decision maker is the person who will be asked to make decisions for you. This can be an individual you name in a Durable Power of Attorney for Health Care (DPOA-HC). If a DPOA-HC is not named, your health care providers will follow Washington state law to determine who can act as your medical decision maker. This means they will as family members or friends to make health care decisions for you. If family or friends cannot be identified from the list below, health care providers may as a court to appoint a guardian to make health care decisions on your behalf.

  Health care providers will contact people in the following order until they can identify a medical decision maker for you (chapter 7.70.065 RCW).

  1. A guardian appointed by a court (if applicable)
  2. Named health care agent (s)*
  3. Spouse or registered domestic partner
  4. Adult children *
  5. Parents *
  6. Adult siblings*
  7. Adult grandchildren who are familiar with the patient*
  8. Adult nieces and nephews who are familiar with the patient*
  9. Adult aunts and uncles who are familiar with the patient*
  10. A close adult friend who meets certain criteria

  *For any group that has more than one person, everyone in the group must agree to the care.

• Why do we ask about pronouns?

  Pronouns are used in everyday speech and writing, including medical communications. When speaking of someone in the third person, using their correct pronouns is a way to accurately acknowledge their gender identity.

• What if a patient asks, “I have an advance directive that says what I want. Why do I need a POLST?”

  You can answer with:

  “POLST provides more assurance that you will get the care you want in an emergency.  It protects you from getting care you don’t want much better than advance directives because it contains actual medical orders.

  Your advance directives are still important if you are choosing to have some medical intervention; they will be used to guide care once you are in the hospital.

  Advance directives cannot be followed as a DNAR order outside of the hospital (since they are not signed by your medical provider).”

• What is the best practice for helping a patient make decisions that will be reflected on the POLST form?

  First and Always: Have the Serious Illness Conversation!
  Listen for Location of Care Preference

  • Elicit patient’s values, goals and preferences with open-ended questions.
    See the Serious Illness Conversation Guide for questions such as:
    “Given the situation, what are your most important goals?”
    “What are your worries and fears?”
    “What abilities feel essential/you wouldn’t want to live without?”
    “How much are you willing to go through?”
  • Listen for answers that indicate a patient values quality of life over quantity.
    “I would go to the hospital, even be on life support but not for very long. I don’t want to be stuck on machines”
    “I wouldn’t want to end up in a nursing home.”
    “I want you can do whatever can get me back home to [take care of myself/be with my family/take care of my spouse].”
    “If I can’t be in my own home, [able to do ___ ], then it’s over.”
  • Make a recommendation to consider POLST if indicated by the patient’s condition and goals.
    “Given what you have told me about your preference to avoid ending up [in a nursing home/unable to care for yourself/on machines], I recommend we complete a POLST form to ensure your wishes will be honored no matter what happens.”
    “Can I tell you a little more about the POLST? “