By Debra Wood, RN, contributor
Some of the foremost ethical issues in nursing, and medicine in general, revolve around end-of-life care. How much should be done to preserve life in terminal cases? And how can you be sure you are supporting your patient’s wishes?
Physician Orders for Life Sustaining Treatment (POLST) documents are an approach to end-of-life care planning that can be followed across health care settings. Yet a 2015 study from the University of Pennsylvania Medical Center found these documents can be misinterpreted.
“POLST forms are incredibly important,” said Carla Braveman, RN, MED, CHCE, vice president for home and community services at the Visiting Nurse Association of Manchester and Southern New Hampshire. “They are relatively new, and every state is dealing with them differently.”
POLST forms are complex, specifying whether the patient wants cardiopulmonary resuscitation (CPR), intubation, antibiotics, a feeding tube, etc. The layers of options make it challenging to determine how to proceed in an emergency situation, so clinicians will often err on the side of life and let staff in the ICU sort it out, Braveman said.
“The beauty of the POLST is its Achilles heel,” she added. “It allows you to drill down and give specifics about what the patient wants, but it’s confusing.”
Confusion about POLST in emergency care
Lead researcher Ferdinando L. Mirarchi, DO, and colleagues surveyed emergency physicians and paramedics about their interpretation of POLST orders. They reported in the Journal of Patient Safety that “significant confusion exists,” and that confusion poses a risk to patient safety.
When the POLST specified Do Not Resuscitate (DNR) and comfort measures only, 10 percent of emergency physicians and 15 percent of emergency medical personnel stated they would perform CPR. When the POLST specified doing CPR, the survey found 95 percent agreement about how to proceed.
“As with any new procedure, training and experience in its use are key,” said Lori Pietrowski, DNP, CRNP, a graduate of the Thomas Jefferson University School of Nursing in Philadelphia. “POLST has been found to adhere to end-of-life care wishes and improve the quality of end-of-life care. In most health care institutions, advance directives are invalid until they take the form of a physician order, whereas, POLST acts as a medical order.”
Amy Calvin, PhD, RN, associate professor of nursing at the University of Texas Health Science Center at Houston School of Nursing, added that “sound research to guide the use of POLSTs needs to continue.”
5 solutions for improving compliance with patients’ end-of-life wishes
1. Nurse advocates. Good communication is essential to helping patients receive the care they desire at end of life. When nurses get to know their patients and families, they are best able to advocate for the patient, Calvin explained. She recommends inquiring about general aspects of life, such as goals and values, rather than leading off with asking about specific plans for end-of-life care.
“Nurses are well positioned to help patients and families understand options and move toward making decisions related to health care near the end of life,” said Connie Barden, RN, MSN, CCRN-E, CCNS, chief clinical officer of the American Association of Critical-Care Nurses.
“Besides knowing what the written advance directives may state, nurses have often had more intimate and detailed discussions with patients about what they want, what they fear and what is important to them.”
2. Patient video messages. A new study led by Mirarchi found that adding a patient-created video testimonial to a living will or POLST form can help to prevent errors of interpretation relating to end-of-life wishes. The study was published in the March 2017 issue of Journal of Patient Safety.
"Our study shows that medical professionals are more likely to reach a consensus after viewing a video testimonial, proving that we can do better than paper forms alone,” said Mirarchi.
3. DNR wristbands. Blima Marcus, BSN, RN, OCN, suggested in a 2015 American Journal of Nursing article that a greater use of color-coded wristbands for DNR orders in the hospital might improve safety, since patients do not always code on their unit. But some argue such wristbands could violate patient privacy, and studies have yet to be done on their efficacy.
Calvin supports the use of DNR wristbands but “only for patients who have expressed their wishes to forgo CPR and mechanical ventilation” and have a DNR order included in the medical record.
4. Clear documentation. “Nurses should be vigilant that all their patients have some type of advance directive on their chart, whether it’s a POLST or some other document,” Pietrowski said, adding that end-of-life decisions should be reviewed with patients and/or family during any change in the patient's medical condition.
Patients’ end-of-life wishes should also be communicated during interdisciplinary meetings to ensure all health care workers are aware of their preferences.
5. Confirmation of patient wishes with family. Family members often have different views on life-sustaining efforts, so it’s important for everyone to know what the patient wanted, said Brenda McSherry, RN, CHPN, case manager at Norwell Visiting Nurse Association and Hospice in Massachusetts.
Education can help. Explaining what CPR will mean for the patient and how it will not change the underlying condition often convinces a family not to block their loved one’s wishes.
Yet, families may struggle as the patient’s condition changes. Nurses at Norwell VNA instruct families to call the hospice rather than 9-1-1 with patients who do not want to be resuscitated. Hospice can manage symptoms and help the person live as full a life as possible until the end.
“End-of-life care is more than providing medical and nursing interventions,” said Jennifer Kennedy, MA, BSN, CHC, senior director of regulatory and quality for the National Hospice and Palliative Care Organization. “It is about providing comfort on all levels and assisting a patient to close their eyes for the last time with peace and serenity.”