October 17, 2013
Area(s) of Interest: Emergency Medicine Emergency Services Patient Care
By True McMahan, M.D.
Emergency department (ED) physicians are a very diverse group of providers. Some of us are cavalier, shooting from the hip as called for by the situation at hand. Others are meticulous and obsessive planners, taking no chances and casting a wide net of differential diagnoses. But MOST, if not all of us, work in a daily melee of balancing a multitude of patients with emergency medical conditions, all the while putting out administrative fires and juggling family and visitors. Is it any wonder then that we crave simplicity? Why not have one less decision, one less stack of nursing home records and advance directive jargon to sift through? That is the beauty of the bright pink POLST form that I have come to know and love.
POLST stands for Physicians Orders for Life Sustaining Treatment. Since 2010, when I first learned of this initiative to simplify and standardize end-of-life wishes, I have been a passionate supporter of its implementation. My hope is that by the end of this article, a few more physicians will be persuaded to join with me in promoting this valuable tool.
First of all, what is it? POLST is a doctor’s order that delineates specific medically appropriate measures desired by the patient or his/her surrogate decision maker should the patient become seriously ill, mostly what we ED physicians and providers call “code three” patients. It is a single piece of paper and is bright pink so that it is easily recognized in a stack of medical records. When used correctly, the POLST follows the patient from acute care to primary care. Stories of its utility include EMS finding it hanging from a patient’s refrigerator when neighbors called 911 and the patient lived alone, and designated health care agents having electronic versions and emailing or faxing a copy to the ED while they are en route.
I challenge all providers in the ED and acute care setting that as physicians we not only have a duty to treat, but to only treat as the patient’s dignity and health goals require. Paternalistic medicine serves to help no one. Non-beneficial care leads to more emotional pain and financial devastation than we realize. As for the ED practitioner, taking a few seconds to find that POLST form, even if hidden in the stack of papers brought in by the paramedics, may mean the difference of peace for patients and their survivors or end-of-life trauma and havoc.
Because the POLST form requires the patient or family to have the courageous conversation about end-of-life wishes BEFORE the crisis, it allows that moment of crisis to be expected, allows us Emergency providers to be facilitators of thoughtful care, while taking the guesswork out of hectic, desperate situations. For me, finding that pink POLST form brings calmness to the gathered team of resuscitators. As I read aloud the wishes delineated on that form, I am able to provide care as if I had just consulted the patient and family, and I can perform that care under the grace of the Hippocratic Oath and with the grace of a doctor who cares about what the patient or family would want.
The California Medical Association (CMA) publishes a POLST kit, available in English and Spanish, which includes legal forms and wallet identification cards, and answers many of the most frequently asked questions about end of life issues. These kits are available in CMA's online store.
For more information on palliative care and POLST, visit www.coalitionccc.org and www.capc.org.
Dr. McMahan is the medical director for the Garden Grove Emergency Department in Garden Grove, CA, and the Associate Medical Director of Emergency Services for Monarch Health Care.