Advance Care Planning & Palliative Care Important During Pandemic: CDPH

On September 22, 2020, the California Department of Public Health posted this all-facilities letter (AFL 20-73), available at  This letter provides guidance to nursing homes about the importance of person-centered advance care planning, including ensuring that current treatment preferences in light of COVID-19 are reflected in up-to-date treatment orders.  

The AFL was the product of a collaborative process initiated by CALTCM Immediate Past President Mike Wasserman, MD, CMD as a modified Delphi group, and subsequently led by the Coalition for Compassionate Care of California.  Numerous other stakeholders helped craft and hone the content of the letter, including but not limited to Health Services Advisory Group (HSAG), California Association of Health Facilities (CAHF), LeadingAge California, the state Ombudsman’s office, UCLA, California State University’s Shiley Institute for Palliative Care, and of course CDPH.  

Among the important points CDPH emphasized in this AFL was the reminder that POLST forms are never mandatory and should not be executed for all nursing home residents.  POLST is not meant to be a generic code status form, but rather a specific order set for patients nearing the end of life (usually defined by National POLST as a life expectancy of 1-2 years or less), especially those who do not want specific kinds of treatment (e.g., CPR in the event of a cardiac arrest).  For some nursing home residents, who merely want standard interventions initially (such as defibrillation and chest compressions for a sudden cardiac event), but may or may not wish prolonged life support now—and who would want to modify their preferences in the event of a significant diagnosis, such as a metastatic malignancy—there is no reason to create a full-code POLST form, since this would create a conflict for health care providers and family members if the patient subsequently lost decisional capacity.  CDPH suggests that facilities provide alternative ways to capture orders for residents’ code status and other treatment preferences.   The previously commonly used Preferred Intensity of Care (PIC) or Preferred Intensity of Treatment (PIT) forms are being used currently in some California facilities, and these may see a resurgence based on the new AFL.  Alternatively, a form to document advance care planning conversations and then placing the corresponding physician orders (e.g., full code, no tube feeding) in the orders and recaps would suffice.

Additionally, the AFL instructs facilities to consider do-not-hospitalize orders for residents who develop COVID, and to ensure residents are given sufficient information to make informed decisions about what services are available in the hospital versus on-site at the nursing home—and information about the poor prognosis of frail, chronically ill elders with severe COVID-19 disease, especially when respiratory failure occurs.  

Finally, the importance of access to palliative care services and comfort medications (e.g., morphine and benzodiazepines) for COVID-19 patients in nursing homes was emphasized in the AFL.  It is suggested that rapid access to advance care planning and palliative care, even if by telemedicine visits, be made a priority.  

CALTCM deeply appreciated the opportunity to work closely with CDPH, CCCC and our other colleagues and stakeholders across the state in creating this important AFL.  We have been heartened by our closer collaboration with CDPH, and by their willingness to consider our input.  CALTCM is creating some content for surveyor training, including a focus on facility medical directors.  Amid the chaos and devastation wrought by this pandemic, a closer working relationship with our regulators and policymakers has been one bright spot.  In the meantime, as this AFL demonstrates, we at CALTCM will continue to advocate for safe, optimal, person-centered care for all who reside and work in post-acute and long-term care settings.

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