Physician orders for life-sustaining treatment (POLST) forms are crucial tools in ensuring that patient treatment preferences are respected and followed, particularly during medical emergencies. As hospitalists, integrating POLST into patient care can significantly enhance decision-making processes, aligning treatments with the patient’s wishes.

Here, we present a clinical scenario demonstrating the application of POLST in a hospital setting, emphasizing the importance of electronic documentation in the patient’s medical record.

Case

Mr. John Smith, an 85-year-old male with a history of advanced chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and stage 4 renal disease, is admitted to the hospital with worsening dyspnea and confusion. He has been hospitalized multiple times over the past year for exacerbations of his chronic conditions. Upon admission, Mr. Smith is found to be in respiratory distress, with a rapid heart rate and low oxygen saturation. His daughter, who is his primary caregiver, arrives shortly after his admission and presents a completed POLST form, which they had discussed with Mr. Smith’s primary care physician during his last visit. The hospitalist team carefully reviews the POLST form with Mr. Smith’s daughter to confirm it accurately reflects his current wishes, as he is currently unable to communicate due to his confusion.

To ensure seamless integration into the care plan, the team takes the following steps:

1. Electronic Upload: The POLST form is scanned and uploaded into Mr. Smith’s electronic health record (EHR), making it readily accessible to all members of the care team across different departments and shifts.
2. Summarization in Notes: The hospitalist documents a detailed summary of Mr. Smith’s wishes as outlined in the POLST form within the progress notes section of the EHR. This includes specific details regarding desired interventions, limitations on life-sustaining treatments, and preferences for comfort care.

The POLST form indicates that Mr. Smith has chosen to:

• Receive limited interventions (no intubation or mechanical ventilation).
• Be treated with non-invasive ventilation and medications to alleviate symptoms.
• Avoid hospital transfers if possible, preferring to be treated at home or in a hospice facility if his condition deteriorates.
• Receive comfort-focused treatments, including pain management and palliative care.

Hospitalist Actions

1. Verification and Communication:

• • The hospitalist confirms with Mr. Smith’s daughter that the uploaded POLST form accurately reflects his current wishes.
  • The team communicates Mr. Smith’s preferences to the entire care team, referencing the POLST form in the patient’s chart.

2. Treatment Plan:

• • Smith is placed on non-invasive positive pressure ventilation (NIPPV) to manage his respiratory distress.
  • Medications are administered to alleviate symptoms and improve comfort, including bronchodilators, steroids, and opioids for dyspnea.
  • A palliative care consult is requested to provide additional support and ensure symptom management aligns with Mr. Smith’s comfort-focused goals.

3. Ongoing Care:

• • Regular assessments are conducted to monitor Mr. Smith’s condition and adjust treatments as necessary.
  • The care team remains vigilant, referencing the POLST form in the medical record to ensure that all interventions respect the boundaries set by his wishes.
  • As Mr. Smith’s condition improves and his mental status clears, the team revisits the POLST form with him to confirm his wishes and make any necessary adjustments, updating the electronic chart accordingly.

Outcome

Over the next few days, Mr. Smith’s condition stabilizes with the non-invasive treatments, and his symptoms are well-managed. His daughter expresses relief and gratitude that her father’s wishes, clearly documented in the medical record, are being honored. This not only reduces her stress but also fosters trust and confidence in the care team.

Conclusion

This clinical scenario illustrates how the effective use of POLST forms, coupled with thorough documentation in the electronic health record, can guide hospitalists in providing patient-centered care, respecting the patient’s preferences, and ensuring that treatments align with their values and goals. By incorporating POLST into routine practice and leveraging electronic tools, hospitalists can enhance communication, reduce unwanted interventions, and improve the overall quality of care for patients with serious, chronic illnesses.

Dr. Patel

Dr. Patel is the chair of the inpatient clinical informatics council, the medical director of virtual medicine, and a hospitalist at Ballad Health System in Johnson City, Tenn. He is also chair of SHM’s Health Information Technology Special Interest Group.

Learn more about POLST in this article Hospitalists Use POLST to Initiate Patient Conversations About Care Goals.