At this years’ CALTCM Summit in Napa, Dr. Eric Widera asked us to “Dust off Our Crystal Ball” regarding the value of predicting the prognosis of a patient and use of the E-Prognosis website (https://eprognosis.ucsf.edu/ ) to improve the reliability of our predictions and recommendations.

Later, Jennifer Ballentine, CEO of the CCCC (Coalition for Compassionate Care, California), presented on “POLST in Practice: Who Decides?” As part of this presentation, she reminded us that the POLST Form is never mandatory and should not be offered to newly admitted SNF residents or Long-term care residents who are unlikely to die within the next 1-2 years. Completion of a POLST is always voluntary and is a medical order that crosses all settings of care and does not expire until it is changed or revoked by the patient or their authorized decision maker. This means a POLST created by a resident when relatively healthy could inappropriately direct medical decisions and create conflicts for both families and clinicians years later when serious illness develops, and the resident no longer has decision-making capacity.

In my county, all outpatient health systems and SNFs are using the POLST to document patient treatment preferences for all their Medicare patients contrary to recommended practice. AHCD (Advance Health Care Directives) are requested, but seldom encouraged. The quality of the advance care planning conversations has been quite variable and sometimes absent. For instance, my wife who is in good health, has had two different PCPs hand her a POLST at her outpatient annual Medicare Wellness exam for her to complete and return without any assistance in how to make her choices or disclosure that it is voluntary or intended only for seriously ill persons. In the SNF setting, the POLST may be presented as a task for nursing to complete on the day of admission along with many other tasks, which may compromise the quality of the POLST conversation and assumes optimal nursing training on POLST completion. For these reasons, our facility medical director has delegated the completion of this form to our physicians (all have completed training on POLST completion) knowing that this is a medical order that doesn’t expire until updated or revoked. 

The CCC has many Advance Care Planning Tools and Resources on their website (https://coalitionccc.org/CCCC/CCCC/Resources/Advance-Care-Planning-Tools-and-Resources.aspx ) to support these important conversations and document choices.  Even if a new admission is in good health, this is a good time to explore ACP issues and encourage completion or update of an advance healthcare directive or if they have one, request access to it. If the resident in good health desires “Attempt CPR” and no restrictions on intensity of care, we recommend documenting that in the physician’s admission note or subsequent progress note and then write an order for “Attempt CPR with full intensity treatment” and avoid completing a POLST selecting Attempt CPR and Full Treatment. . This process will meet our SNF regulatory requirement to ensure the CPR status of each resident is known and respected. The process would be the same for residents who are seriously ill, but do not want to complete the POLST. However, for those who are in their last 1-2 years of life and willing to complete the POLST, we do recommend its completion and writing the chosen CPR status as a written order. 

Once a POLST is completed, facilities should make a copy for their records but send the original POLST home with the patient and instruct them to place it on their refrigerator or with their medicines so the paramedics will see it. In my community, hospitals don’t send the original POLST back to SNFs, so we send a copy of the POLST and keep the original for discharge home with the patient.  Hopefully, this problem will be corrected when we have our statewide California POLST registry up and running. 

The CCCC has revised its model SNF POLST Policy and is scheduled to post it on their website in the near future.

Is it time to update your facility ACP policy so it is consistent with best practices?