Milestones of the Oregon POLST Program (1990-Present)
1990: Oregon POLST Task Force Formed
1993: Early Evaluation
1995: POLST Release
1999: EMT/First Responder Scope of Practice Change
2001: Minors Added
2002: Nurse Practitioner Added as Signers
2002: Trauma System Enrollment
2007: POLST Orders to be Honored in All Oregon Health Care Facilities and Physician Assistant Added as Signers
2008: POLST and Persons with Disabilities
2009: Oregon POLST Registry
 1990: Oregon POLST Task Force Formed
Clinical ethics leaders recognize that preferences for life-sustaining treatments of patients with advanced chronic progressive illness are frequently not found or not transferable and thus not honored. A task force was convened by the Center for Ethics in HealthCare at OHSU with representatives from stakeholder health care organizations to develop a new method to translate patient preferences into actionable medical orders that follow patients across settings of care. The original form, known as the Medical Treatment Coversheet, included a set of portable standard medical orders regarding life-sustaining treatments based on a patient’s preferences including those in an advance directive. The task force decided to develop and implement the form through a grassroots improvement in the standard of medical care and selected administrative rule changes. A legislative approach was not pursued due to concerns that the need may  not be met best by legislation.
1993: Early Evaluation
The Medical Treatment Coversheet was refined with focus group feedback from clinicians caring
for patients in acute and long-term settings
(see annotation of Journal of the American Geriatrics Society, 44, 785-791). The name was changed to “Physician Orders for Life-Sustaining Treatment (POLST)” to distinguish the medical order form more clearly from a traditional advance directive. Pilot testing of POLST orders in nursing homes in a rural small town, medium sized city and the Portland metropolitan area demonstrated the effectiveness of the POLST form (see annotation of Journal of the American Geriatrics Society, 46, (9), 1097-1102).
1995: POLST Release
Confident in the early evaluation findings, the task force released a slightly revised version of the POLST form for use throughout Oregon. The implementation process included ongoing education through existing member organization communication resources and conferences. The task force employs a continuous quality improvement method to actively solicit feedback from clinicians using the form. We also use data from research. For example, a prospective one-year study of POLST form use in nursing homes demonstrated effectiveness; no resident with orders for Comfort Measures Only and DNR received CPR, ventilator support or ICU care (see annotation of
Journal of the American Geriatrics Society, 46, (9), 1097-1102).
1999: EMT/First Responder Scope of Practice Change
For the POLST form to be effective in honoring patient preferences for treatment, the orders needed to be followed by emergency personnel who needed to feel that they had protective immunity. The task force recommended a change in the Oregon Medical Board’s administrative rule that defines the scope of practice for EMT’s/First Responders (OAR 847-035-0030). The Board approved language states:
An Oregon-certified First Responder or EMT, acting through standing orders, shall respect the patient’s wishes including life-sustaining treatments. Physician supervised First Responders and EMTs shall request and honor life-sustaining treatment orders executed by a physician, nurse practitioner or physician assistant if available. A patient with life-sustaining treatment orders always requires respect, comfort and hygienic care.
2001: Minors Added
Community clinicians requested the task force consider use of the POLST form for children with terminal illness. A community and task force consensus process included focus group input from various professionals and health care organizations  that care for children and from the school system. Section E of the POLST form was modified to include “parent of minor” to indicate the legal decision-maker for most children.
2001: Nurse Practitioner Added as Signers
Nurse practitioners (NP’s) provide a substantial service as primary care professionals to Oregonians, especially in rural areas. In the early years of the program POLST forms for NP patients needed to be signed by a supervising physician even though these orders were similar to other medical orders not requiring this signature. The task force worked with the Oregon Board of Nurses in determining that POLST orders are within the scope of practice for NP’s and therefore does not require physician co-signature. The task force worked with EMS to ensure that NP orders would be respected by emergency personnel under protocols affirmed by their physician supervisors.
2002: Trauma System Enrollment
Trauma patients who met trauma system enrollment criteria were routinely treated using the trauma system protocol for both treatment and transport. Many times this included patients with advanced progressive illness or terminal condition not wanting the intensive treatment and transfer otherwise mandated within the trauma system. The task force worked with the State Trauma Advisory Board (STAB) to establish criteria for enrollment of patients with a POLST form. These criteria are:
The patient with “DNR” marked in Section A and either “Comfort Measures Only” or “Limited Additional Interventions” marked in Section B of the patient’s POLST form should not be entered into the trauma system and does not require a trauma team response following a traumatic incident. This patient may require pre-hospital transport to the hospital for comfort care.
To provide guidance for health professionals caring for an injured patient with POLST orders excluding the patient from enrollment in the trauma system, the task force developed educational tools for clinicians (see “POLST and the Injured Patient”)
2007: POLST Orders to be Honored in All Oregon Health Care Facilities and Physician Assistant Added as Signers
In 2006, some hospital ED physicians were reluctant to follow POLST orders signed by a physician, NP or PA that was not on their medical staff; concerned that the signer had ‘no standing’ in their facility. These ED physicians were feeling the need to redo the entire informed consent process for life-sustaining treatments with the patient or surrogate without the benefit of the prior process as documented in the POLST orders. In addition, leaders in the physician assistant (PA) professional community requested that PA’s be considered as signers of the POLST order. Similar to NP’s, PA’s provide substantial primary care to patients in Oregon.
To address each of these issues, the task force worked with the Oregon Medical Board (OMB) to establish new administrative rules. The rules require that a physician and PA respect orders regarding life-sustaining treatments and provides protective immunity. Also, in keeping with their scope of practice, the Oregon Medial Board agreed that PA’s should be valid signers of the POLST form, similar to other medical orders and with the same oversight as normally provided by the supervising physician. The Board included PA’s in rule changes regarding respecting orders for life-sustaining treatment in all Oregon health care facilities (OAR 847-010-0110).
(1) A physician or physician assistant licensed pursuant to ORS chapter 677 shall respect the patient’s wishes including life-sustaining treatments. Consistent with the requirements of ORS chapter 127, a physician or physician assistant shall respect and honor life-sustaining treatment orders executed by a physician, physician assistant or nurse practitioner. The fact that a physician, physician assistant or nurse practitioner who executed a life-sustaining treatment order does not have admitting privileges at a hospital or health care facility where the patient is being treated does not remove the obligation under this section to honor the order. In keeping with ORS chapter 127, a physician or physician
assistant shall not be subject to criminal prosecution, civil liability or professional discipline.
(2) Should new information on the health of the patient become available the goals of treatment may change. Following discussion with the patient, or if incapable their surrogate, new orders regarding life-sustaining treatment should be written, dated and signed.
2008: POLST and Persons with Disabilities
Disability Rights Oregon brought questions and requests for clarification about how a POLST form should be best used in persons with disabilities. A need for greater education of health care professionals was identified. The task force worked with the professional care community and organizations representing persons with disabilities to develop improvements to the POLST form (see Section E addition of “special consideration needed for persons with significant physical disabilities, developmental disabilities and/or significant mental health condition” who are now near the end of life), our guidance to health care professionals and organizations.
2009: Oregon POLST Registry
The Registry project began under the leadership of Terri Schmidt, M.D. in January 2008 in response to a need expressed by Emergency Medical Services (EMS) to access POLST orders when they arrived on the scene of a medical emergency, and could not immediately locate the original POLST form. The development of the test and pilot systems were funded by a grant from The Greenwall Foundation along with additional private philanthropy. The project is a collaboration of the Oregon POLST Task Force, the OHSU Center for Ethics in Health Care and the OHSU Department of Emergency Medicine.
The first phase of the project consisted of designing the electronic Registry and was completed in December 2008. In January 2009, the second phase began, with system training and testing of the developed Registry by the project team, the OHSU Emergency Communications Center and EMS professionals in Clackamas County. May 2009 marked the roll out of the third phase or “pilot” of the Oregon POLST Registry with initiation in Clackamas County on May 26, 2009.
Concurrently, legislation was introduced to partner with the state Department of Human Services and newly formed Oregon Health Authority to address HIPAA requirements and to secure support for statewide expansion. The legislation became law on July 1, 2009 and the Registry office began accepting forms from all of Oregon. On December 3, 2009 the Registry was implemented statewide.
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