To: Ethics Advisory Board
From: Concerned skilled nursing facility nurse
Subject: POLST and long-term care

I’m a new RN on the night shift at a skilled nursing facility (SNF) in California. The admissions clerk, who isn’t a healthcare professional, is required to obtain a Physician Orders for Life-Sustaining Treatment (POLST) form signed by the patient or family, along with numerous other documents, on admission.

Many of our long-term residents have a POLST form on file stipulating full treatment, which requires staff members to start cardiopulmonary resuscitation (CPR) and call 911 emergency services. Recently on my shift, a frail long-term resident with multiple chronic conditions was found in cardiac arrest. She had signed her full code POLST when she was admitted 5 years ago for short-term rehab with a plan to return home. We initiated CPR and called 911. The paramedics who responded were quite upset that this resident had a “Full Treatment” POLST. Their resuscitation efforts understandably were unsuccessful, and she was pronounced dead at the scene. I too was upset that we subjected this patient to unnecessary suffering at the end of her life. What can I do to prevent this scenario from recurring in the future?

From: ANA Center for Ethics and Human Rights

Going through this experience no doubt created a great deal of moral distress for you and the others involved. It would be a good idea for the SNF’s 
management to review their organizational policies related to POLST. 

POLST began as a national effort to provide a way for individuals facing serious illness or frailty to clarify their end-of-life wishes. Today, each state has its own version, some using different acronyms. POLST requires a conversation between a patient and/or their family, and a healthcare professional so that the individual is fully informed of the medical issues involved. A POLST form then becomes a physician’s order upon completion. As a patient’s condition changes, their POLST should be re-evaluated and a new POLST completed as appropriate. Notably, if a facility’s default is to provide full treatment including resuscitation efforts and this is consistent with an individual’s wishes, then completing a POLST isn’t indicated and potentially can cause problems in the future if a patient’s condition changes (as it did in the case you describe).

Provision 1.3 of the Code of Ethics for Nurses with Interpretive Statements (the Code) tells us that “nurses respect the dignity and rights of all human beings” and that this respect includes “alleviation of pain and suffering” 
(nursingworld.org/coe-view-only). You couldn’t do this because of an institutional policy regarding POLST that needs to be evaluated at a higher level. Provision 3.5 of the Code says that when practices within an organization “threaten the welfare of a patient” nurses should express their concern to management. Provision 6.3 concurs: “Nurses should address concerns about the healthcare environment through appropriate channels.” It’s clearly within your scope of practice to reach out to the facility’s management and request clear policies regarding POLST along with inservice education for both clinical and non-clinical staff members. Care plan reviews also should include re-evaluations of advance care planning documents such as advance directives and POLSTs.

— Response by Chris Wilson, JD, MS, RN, HEC-C, member 
of the ANA Ethics and Human Rights Advisory Board

For further information
POLST for Health Care Professionals. National POLST Web Site. (polst.org/professionals-page/?pro=1)
POLST for Healthcare Providers. POLST California Web Site. (capolst.org/polst-for-healthcare-providers)