Approach to Implementation of a POLST Paradigm Program

Share your program information (become "light pink" on the map)

Seek endorsement of your developed program (become "dark pink")

1. Do a needs assessment -

   Is the system working well already to identify and respect patients’ preferences for end-of-life care? Are patients who wish to have orders to limit life-sustaining treatments such as DNR clearly identified and are those wishes being respected? Are seriously ill patients who wish to remain at home or in a long-term care facility able to receive comfort care in those settings or are they transported to the hospital? The needs assessment should be done with EMS, ED physicians and nurses, and social workers in long-term care facilities and hospitals.

2. Assemble a Core Working Group -

   If the system is not working well, assemble a core group who believes the POLST Paradigm is a good idea and becomes well educated about the POLST Paradigm so that core group members can explain it to others and enlist their participation.

3. Assemble a Task Force with Broad Representation -

   This task force should include representatives from EMS, emergency department physicians and nurses, the state long-term care association, the state medical association, the state surveyors, the agency responsible for senior services, the state department of health, the state hospital association, home health association, the state bar association and the state hospice association. Other groups may also be considered for inclusion such as organization(s) that represent health care for seniors representatives from minority groups in the state, the statewide ethics committee network, and one or more legislative champions who can provide counsel and representation regarding possible legislation. Representatives of the disability community or interested right-to-life organizations can be consulted as needed and may not need to serve on the task force.

4. Conduct a Pilot Project -

   Consider conducting a voluntary pilot project in one or more communities. Enlist all the local long-term care facilities, the local EMS, the local emergency department personnel, all the local hospitals, home health, and hospice. Be sure to provide training for the social workers and nursing so they know how to talk to patients and families about the POLST Paradigm form. Create a regional task force composed of representatives from these entities and meet monthly to implement the pilot project and then to review the results and share them with other members of the statewide task force.

5. Address Legal Issues -

   Under your state law, can a POLST Paradigm Program be developed by state regulations or will it require legislation? Look at examples of states that have chosen the legislative route (West Virginia, Tennessee, and Hawaii) or the regulatory route (Oregon, Utah, and Washington). Consider whether you want to have the POLST Paradigm form signed by a physician only with the patient/legal agent’s signature optional (as is the case in Oregon) or if you want the patient/legal agent’s signature mandatory (as is the case in West Virginia). In West Virginia, the minority representatives on the task force requested that the patient’s signature be mandatory or else they would not support development of the form. Also, consider if the orders can be signed by a health care professional other than a physician. For example, primary care in some areas of a state may be primarily provided by nurse practitioners or physician assistants. Some state medical associations (e.g., West Virginia State Medical Association) may not want other health care practitioners to have the authority to sign the form. This issue may require discussion.

6. Train Health Care Professionals -

   Train social workers, nurses, chaplains, and others to be advance care planning facilitators so that they are comfortable and knowledgeable discussing the POLST Paradigm form.

7. Program Coordination -

   From the initial task force, consider the best method to coordinate the program long-term, operationally and financially. Some states have chosen academic ethics centers, medical associations, or the department of health as sometimes mandated by legislation. The best option will vary based on state specific factors. The necessary components of the system are as follows: 1) standardized practices, policies, and form; 2) trained advance care planning facilitators; 3) timely discussions prompted by prognosis; 4) clear, specific language on actionable form; 5) a bright form easily found among paperwork; 6) orders honored throughout the system; and 7) quality improvement activities for continual refinement of the form and the system.

8. Distribution Plan -

   Determine how you plan to distribute the form. In some states, the form is downloadable from a website, and there is not readily available data on the use of the form without further research being done. In other states, the forms are numbered and distributed from a central office, and there is close monitoring of who is using the forms and how many. The method of distribution of the form has obvious financial implications.

9. Review Program Components -

   Review the possible POLST Paradigm components and core requirements. If your program meets the core requirements, apply on the website for endorsement as a POLST Paradigm program.

10. Relationship to Media -

    Consider the interface of your project to the media. What message do you want to consistently portray? Which message do you want to avoid? Having individuals on your task force that have good public communication skills can be helpful. Thinking through a media plan and messages in advance can avoid later challenges.

11. Use Available Resources (see Resources) -

    The National POLST Paradigm Initiative Task Force is available to help you. Also, there are experienced colleagues in various states that are available. The task force and website can help facilitate understanding, development, education, and evaluation regarding your program regardless of level of development.

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