A valid POLST Form on a resident with dementia living in a memory unit (licensed as a Residential Care Facility for the Elderly {RCFE}), called for DNR, comfort-focused treatment, meaning generally do not transfer to the hospital. Yet when he developed acute altered mental status (AMS), his wife was surprised and dismayed that the facility could not provide comfort-focused care and needed to send him to the ER. To those working in the PALTC space, this is not a surprise, since most ALFs (Assisted Living Facilities) do not have the expertise or quick access to palliative care meds. By Title 22 regulations, they must transfer their residents to the ER for potentially serious changes of condition. In addition, AMS has many potential causes, some of which are potentially reversible like a systemic infection or electrolyte abnormality. Of course, in the case above, the resident was not suffering any significant symptoms that were bothering him; he was just more lethargic. With comfort-focused treatment preferences, no workup or changes in therapy would typically be warranted. 

These situations with unwanted and medically unnecessary transfers are unfortunate but frequent, and they are despised by almost everyone involved: patient, family, EMTs, ED personnel, and RCFE staff. But they are a legal and regulatory requirement as it stands now. Over the years, there has been talk of legislation to modify this, but it hasn't happened yet.

In 2009, my 88 y/o mother had recently been diagnosed with colon cancer and chose a palliative care approach, stating she never wanted to go back to the ER again. She was living in an RCFE for care and had a history of mixed dementia, atrial fibrillation, hypertension, and O2-dependent COPD. At her subsequent hospice information visit, she was advised that enrollment in hospice would help her access timely care for future emergencies without having to go to the ER and that without this benefit, the facility would have to send her to the ER. Unfortunately, her roommate with ESRD had recently quickly died on hospice after discontinuing hemodialysis. My mother, as an observer, concluded that hospice “kills” people. She also was sure that her refusal to return to the ER would be honored by the facility. I decided to not override her firm refusal of this benefit. About 6 weeks later, she was hospitalized with UTI with sepsis. On return to her ALF 4 days later, she accepted hospice and became a big fan, when our hospice chaplain sang Lutheran hymns with her during his visits. She went on to live another year with prompt management of changes of condition by the hospice team, good quality of life and stable function, and no further return to the acute hospital. 

As a hospice medical director who worked full time in the post-acute and long-term care (PALTC) space, I was aware of the importance of having timely onsite care for my mother and patients like her who have serious illness and no longer want potentially life-prolonging care. 

Completing a POLST for comfort-focused treatment is an insufficient care plan in the ALF space; it does not work that well in the SNF environment either. Patients and families need to know the limitations a facility has for managing changes of condition in house, particularly after hours and on the weekends. They should be given options for how onsite management might occur. 

Hospice is usually the best option for those with a qualifying diagnosis. However, if the patient does not yet qualify, honoring this request may still be an option if the patient’s provider(s) are committed to timely in-person assessment of changes of condition, and the patient has an emergency “comfort” med kit available. Hospice evaluation visits, even for patients who may not qualify, can be helpful, and can help set expectations for how future emergencies may be managed. Connecting the patient with community-based palliative care services, offered separately as a standalone service can be an option too.  

When there is a significant change of condition in a person with serious illness, this is a good time for facilities and providers to set up a family conference and explore what kind of future care the resident would desire for future emergencies. For my mother, I was able to coordinate that level of care. Are you providing similar care for all your residents and their families?