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Developing a Program

Program Requirements

National POLST Paradigm Program Requirements

The National POLST Paradigm Task Force (NPPTF) has developed this description of the POLST Paradigm Program to further clarify requirements for a state or region POLST Paradigm Program. The NPPTF believes this clarification is necessary because of the variation in proposals for programs and forms that the NPPTF has been receiving. The goal of this description is to make more explicit the standards that are presently being met by endorsed POLST Paradigm programs.

This description will continue to be refined based on input from all involved in the process of establishing or strengthening POLST Paradigm programs. The NPPTF is designing a three tier endorsement process for developing, endorsed and mature POLST Paradigm Programs. This clarification will be included in the tier for endorsed programs.

 

Program Structure

  1. Has an effective statewide or regional coalition(s). If there are regional coalitions, they are working on a coordinated strategy towards state wide implementation.
  2. Identifies and builds a research and quality assurance component.
  3. Champions are identified and active in the program implementation and education.

 

Program Requirements

In order to be considered an endorsed POLST Paradigm Program, the Program must include these requirements:

  1. The form constitutes a set of current (in some states they may be accepted as standing) medical orders.
  2. The process includes ongoing training of health care professionals across the continuum of care about the goals of the program, the creation and use of the form, and how to conduct a POLST conversation.
  3. Use of the form is recommended for persons who have advanced chronic progressive illness and/or frailty, those who might die or lose decision-making capacity in the next year or any one with advanced age with a strong desire to further define their preferences of care in their present state of health.
  4. As allowed by statute and regulations, the National POLST Paradigm Task Force strongly recommends that all POLST Paradigm Programs require the signature of either the patient or the patient’s legal representative (or witnessed verbal consent as allowed by and in accordance with state law) to make the form valid. The signature of the patient (or the patient’s legal representative if the patient lacks decision-making capacity) provides evidence that patients or their legal representatives agree with the orders on the form. In this respect, the requirement that patients or their legal representatives review and sign the form provides a safeguard for patients that the orders on the form accurately convey their preferences.
  5. Completion of a POLST Paradigm form is a recommended preferred practice for advance care planning in multiple health care settings (eg, emergency medical services, long-term care, hospice, and hospice). Completion of the form and the decisions recorded on it should be voluntary, include informed consent and shared informed medical decision making. The completion of a POLST Paradigm form should be based on the patient's goals for care to ensure that the patient receives the treatment he or she desires.
  6. There is a plan for ongoing evaluation of the program and its implementation.
  7. There is a single strong entity within the region or state that is willing to accept ownership for the program (e.g., hospital association, state dept of health, hospice and palliative care association, university-affiliated ethics center, etc) and has the resources to implement it.


Form Requirements

The form content includes:

  1. The treatment being considered requires a medical order that needs signature by a health care professional.
  2. The medical order is based on the patient’s goals of care and a person’s preferences for treatment (e.g. as expressed in an oral statement or written advance directive).
    • The treatment is a “comfort measure”; or
    • The order is an instruction regarding hospital transfer; or
    • The medical order is a life-sustaining treatment that is being considered for use in a person with advanced progressive illness and/or frailty and has these characteristics:
      • is frequently needed by health care professionals (e.g. EMS protocol, emergency department and ICU care, long-term care or hospice); and/or
      • is urgently needed by health care professionals (e.g. EMS protocol, emergency department and ICU care; long-term care or hospice); and/or
      • requires an informed consent process that is complex (e.g. tube feeding treatment); and/or is not effectively specified as “Additional orders”.  
  3. The written medical orders explicitly state in the medical orders section that comfort measures are always provided and may require transfer to another setting of care (e.g. “Transfer if comfort needs cannot be met in current location”. The medical order set should also state that food and fluids are always to be administered by mouth if medically feasible (e.g. offer food by mouth if feasible).
  4. In addition to orders with regard to CPR, the POLST Paradigm form must indicate the level of medical intervention for the patient: comfort measures only; limited additional interventions; or full treatment. The level of intervention shall contain a description of the services to be provided and the site in which they will be provided. For example, a comfort measures order may indicate that the patient is not to be transferred unless comfort needs cannot be met in the person’s current setting.
  5. The form requires a valid clinician (Physician, Nurse Practitioner or Physician Assistant depending upon POLST paradigm program) signature and a date of signature. The medical orders should be signed and dated to clearly show the most current orders.
  6. The form provides explicit direction about resuscitation (CPR) instructions or patient preferences if the patient is pulseless and apneic.
  7. The form also includes directions about other types of intervention that the patient may or may not want. For example, decisions about transport, ICU care artificial nutrition, etc. Space is provided for additional orders.
  8. The form accompanies the patient, and is transferable and applicable across all care settings (i.e. home, long-term care, hospice, EMS, hospital).
  9. The form is uniquely identifiable and standardized within a state/region.
  10. The form indicates with whom the orders were discussed or who provided informed consent.
  11. The form indicates a transfer option if the patient’s comfort needs cannot be met in the current setting of care.
  12. The form indicates on the front page the name of the state. The form may indicate that the program is an endorsed POLST Paradigm program.

Optional Elements

The following issues may be handled by programs in different ways depending on state law and local preferences.

  • Ideally, a legal surrogate should be able to make decisions about treatment choices and complete a POLST Paradigm form for a patient without decision-making capacity, but states have varying laws regarding surrogates and decision-making.
  • Some states may recognize the form as the only out-of-hospital DNR form; in others there may be other means of DNR ID as well. Use of the form is always voluntary.
  • Ideally, states would accept forms completed in other states (reciprocity).
  • Medical orders may address artificially administered nutrition and hydration. This may vary based on medical practice standards, regulations or laws of that state.
  • The National POLST Paradigm Task Force strongly recommends that all original, paper POLST Paradigm forms have a bright, easily seen uniform color but recognizes that FAXED or electronic representations of the POLST Paradigm form on white paper are valid.

 

Effective Date: These requirements were adopted June 23, 2011 and continue to be revised based on requests of developing programs to provide greater direction and clarity with regard to requirements for an endorsed POLST Paradigm program

States previously endorsed are encouraged to work with their coalitions to meet the new endorsed and mature program requirements within the next 3 years. Prior endorsements may be revoked if that state cannot show progress toward meeting at least Tier 2 criteria.

 

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