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Florida’s Physician Orders for Life-Sustaining Treatment

The Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST) is a program that can offer an effective method for ensuring that patients’ choices regarding end-of-life (EOL) are honored (Braun, 2016; National POLST Paradigm, 2017).

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Even though advanced directives (ADs) can be effectively used for the designation of health care representatives who can act on patients’ behalf, they are rarely available during the process of admission to a hospital. Moreover, even if patients have signed ADs, “they do not provide orders that first responders can follow” (Schmidt, Zive, Fromme, Cook, & Tolle, 2014, p. 480). Out-of-hospital Do Not Resuscitate (DNR) order is another method of ensuring that patients receive treatment according to their preferences.

However, they take effect only after an individual is in a critical condition, thereby divesting health care professionals of the freedom to make important care decisions before the critical moment (Schmidt et al., 2014). To address these and other deficiencies of existing legal solutions for the problem of honoring patients’ wishes and preferences regarding EOL care, POLST was created in Oregon in 1991 (Braun, 2016). The Terri Schiavo case was one of the reasons behind developing the program which is based on near the end of life counseling followed by the submission of a POLST form (Braun, 2016).

The National POLST Paradigm Task Force (NPPTF) is an organization created to actively support and propagate the implementation of the program in the U.S. (Braun, 2016). As of 2016, the POLST program was implemented in more than 40 states and became an inherent feature of advance care planning in 19 states (Braun, 2016).

This paper aims to present a proposal for making the POLST program a part of the health care policy of the State of Florida. It will look at the most current evidence for the necessity of policy change and examine opposing arguments.

Legislation Type

The policy change proposal calls for state legislation aimed at the adoption of the POLST paradigm in the State of Florida. Moreover, there is also a need to create an electronic registry of POLST forms akin to one utilized in the State of California since 2016 (Buck, 2016). Furthermore, the State of Florida should issue a bill allowing nurse practitioners and physician assistants to “sing POLST forms and make them actionable medical orders” (Buck, 2016, para. 3).

Literature Review

A recent article examining the experience of 40 states that implemented POLST programs suggests that it is an extremely effective tool for making sure that patients’ EOL wishes are honored (Braun, 2016). There is ample evidence suggesting that “treatments provided at the end of life matched the orders on the form” (Braun, 2016, p. 1111).

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The proponents of the implementation of the program argue that unlike ADs that are rarely available and often ambiguous, POLST forms are more effective in helping to plan advance care. Moreover, taking into consideration the fact that a POLST form can be filled in by surrogates, it can be used in cases in which it is not possible to complete it by an individual without a decision-making capacity (Braun, 2016). Furthermore, “POLST forms are binding medical orders” (Braun, 2016, p. 1112); therefore, they make the completion of an AD unnecessary.

An article examining the application of the POLST paradigm in nursing homes brings to attention the fact that the inability of incapacitated patients with a limited decision-making ability to take care of their EOL treatment wishes is the main reason for implementing the use of POLST forms (Kapp, 2014). The author argues that the implementation of the POLST paradigm can help in correcting many of the inadequacies of ADs. Namely, the forms can assist in lessening “the discrepancy between a patient’s end-of-life care preferences and the treatment(s) eventually provided by the patients’ health care providers” (Kapp, 2014, p. 169).

Another article exploring how POLST documents are being used for patients transferred to nursing facilities reveals that the forms alter the kind of EOL care that patients receive. In the case of resuscitation, 98 percent of treatments corresponded to those in POLST forms (Hickman, Nelson, Smith-Howell, & Hammes, 2014). EOL care provided to the patients that have submitted POLST documents was also consistent with POLST orders for medical interventions and antibiotic use in 92 percent and 93 percent of cases, respectively (Hickman et al., 2014). The article also indicates that POLST forms can be used for tracking treatment decisions over time to easily detect “inconsistency between treatment orders and decisions about treatment limitations” (Hickman et al., 2014, p. 45). It might lead to the improvement of the process of POLST creation, thereby significantly enhancing the quality of advance health care planning.

The advocacy for policy change is supported by The New York Times article “The Trouble with Advance Directives” by Paula Span. The author recognizes numerous deficiencies of ADs and provides two examples were patients’ directives were outright neglected by health care professionals. Span (2015) notes that while POLST cannot become a substitute for ADs, their use “does a better job than advance directives of keeping dying people out of hospitals” (para. 9). After all, ADs are not medical orders and do not prevent health care professionals from attempting resuscitation regardless of the information provided in them.

An article published in The Washington Post quotes the president of the National Academy of Elder Law Attorney, Howard Krooks, who says that ramifications of not having a POLST form or at least an AD “are so severe that it’s bewildering that more people don’t do it” (as cited in Consumer Reports, 2015, para. 2). The author of the article recognizes the necessity to spell out EOL care wishes. They also join the group of scholars studying the issue of near the end of life health care treatment who argues that a POLST form is one that can significantly benefit patients who might die within a short period. Unlike an AD, a POLST document provides health care professionals with more specific details about a preferred treatment such as whether a patient wants “to be tube-fed indefinitely, on a trial basis or not at all” (Consumer Reports, 2015, para. 9).

The advocacy for the policy change is supported in the article titled “Err on the Side of the Patient” published in The Huffington Post. The author of the article states that the need to implement the POLST paradigm across the U.S. requires urgent recognition. She notes that a POLST form is a document that can regulate a kind of EOL treatment provided to a patient regardless of whether they are “at home, in transit, or the hospital” (Zitter, 2015, para. 7). Therefore, critically ill patients can significantly benefit from signing a document enabling them to choose whether they would like to be subjected to life-sustaining treatment.

According to Buck (2016), POLST forms are so essential in emergencies that their availability has to be extended to every state. The author keeps in high regard a recent trend of the implementation of the POLST paradigm—an electronic registry of the documents. She calls for a pilot program assessing the feasibility and effectiveness of a statewide registry database. Buck (2016) notes that patients signing a POLST form are provided with the choice between full, selected, and comfort-focused treatments. Therefore, it is necessary to provide all citizens of the country with such an option by implementing the POLST paradigm across the U.S.

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Current Policy

The Chapter 765 of the Title XLIV of the State of Florida Civil Rights Statute recognizes two conditions for the discontinuation of life-prolonging procedures for a patient in a persistent vegetative state if an AD is absent (The Florida Legislature, 2009). The first condition for rejecting such procedures is that “the person has a judicially appointed guardian representing his or her best interest with authority to consent to medical treatment” (The Florida Legislature, 2009, para. 2). The second condition, which has to be met to satisfy statute requirements, states that a judicially appointed guardian should have an appointment with a medical ethics committee. Moreover, they have to “conclude that the condition is permanent and that there is no reasonable medical probability for recovery and that withholding or withdrawing life-prolonging procedures is in the best interest of the patient” (The Florida Legislature, 2009, para. 3).

The issue is extremely important for the health care delivery process in the State of Florida because it lacks a proper legal structure helping health care professionals to honor EOL decisions of seriously-ill patients.

Proposed Policy

There is ample evidence suggesting the effectiveness of POLST documents in making sure that patients’ preferences for EOL treatment correspond to those provided by health care professionals in emergencies (Hickman et al., 2014). Therefore, it is necessary to make POLST law in the State of Florida. The opponents of the policy change argue that POLST forms will replace ADs. However, they should be informed that AD will still be needed in order “to appoint a legal healthcare decision-maker, and is recommended for adults, regardless of their health status” (California Catholic Conference, 2015).

Stakeholders

Signing POLST into law in the State of Florida will substantially benefit patients who want their EOL care preferences to be properly honored. Other groups of stakeholders interested in the policy change include physicians, physician assistants, advanced practice nurses, and other health care practitioners. Pro-life Healthcare Alliance and numerous Catholic organizations are the main opponents of the legislation (California Catholic Conference, 2015; Pro-life Healthcare Alliance, 2015).

Expected Outcomes

As a result of the policy change, physicians will be able to discuss with patients their wishes regarding EOL care. Moreover, the legislation will change both the nursing practice and the health care system of the state by creating a legal structure helping health care professionals to honor the EOL preferences of seriously-ill patients. The goal of the proposed policy change is to “facilitate patients’ choices regarding EOL care, in particular, life-sustaining medical treatments” (Braun, 2016, p. 1112). It is possible to measure the effectiveness of the implementation of the POLST paradigm by comparing treatments provided to dying patients with orders in their forms.

Reflective Practice

My experience shows that ADs can be ambiguous and are not always present. Moreover, unlike POLST forms they are not legally binding. The proposed change will affect my practice by allowing me to sign POLST forms. As a result, health care delivery in my community might be significantly improved because approximately 13 percent of all POLST forms are invalid due to the lack of physician signatures (Braun, 2016). The health of patients in my area will also be improved if POLST is signed into law in the State of Florida.

Conclusion

POLST is a program that can offer an effective method for ensuring that patients’ choices regarding end-of-life (EOL) are honored (Braun, 2016; National POLST Paradigm, 2017). The current policy allows the use of ADs and the appointment of a legal guardian who will act on a patient’s behalf in deciding whether to accept or reject life-sustaining health care procedures (The Florida Legislature, 2009). The policy change proposal calls for state legislation aimed at the adoption of the POLST paradigm in the State of Florida. There is ample evidence suggesting that signing POLST into law in the State of Florida will substantially benefit patients who want their EOL care preferences to be properly honored. The main expected outcome of the legislation is the change of both nursing practice and the health care system of the state by creating a legal structure helping health care professionals to honor EOL preferences of seriously-ill patients. Therefore, it is necessary to change the opinions of Pro-life Healthcare Alliance and numerous Catholic organizations that oppose the policy change.

References

Braun, U. (2016). Experiences with POLST: Opportunities for improving advance care planning. Journal of General Internal Medicine, 31(10), 1111-1112.

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Buck, C. (2016). What’s a POLST? These pink forms spell out your life-saving preferences. The Sacramento Bee. Web.

California Catholic Conference. (2015). A FAQ on POLST and Advanced Directives. Web.

Consumer Reports. (2015). For young and old, it’s wise to have a living will to state health-care wishes. The Washington Post. Web.

Hickman, S., Nelson, C., Smith-Howell, E., & Hammes, B. (2014). Use of the Physician Orders for Life-Sustaining Treatment program for patients being discharged from the hospital to the nursing facility. Journal of Palliative Medicine, 17(1), 43-49.

Kapp, M. (2014). The nursing home as part of the POLST paradigm. Hamline Law Review, 36(2), 151-175.

National POLST Paradigm. (2017). What is POLST? Web.

Pro-life Healthcare Alliance. (2015). Statement of opposition to POLST. Web.

Schmidt, T., Zive, D., Fromme, E., Cook, J., & Tolle, S. (2014). Physician Orders for Life-Sustaining Treatment (POLST): Lessons learned from analysis of the Oregon POLST registry. Resuscitation, 85(4), 480-485.

Span, P. (2015). The trouble with Advanced Directives. The New York Times. Web.

The Florida Legislature. (2009). The 2009 Florida Statutes. Web.

Zitter, J. (2015). Err on the side of the patient. The Huffington Post. Web.

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