Life Matters Media
Quality of life at the end of life

Nurse Practitioners Increase Access To POLST

BY DANIEL GAITAN | daniel@lifemattersmedia.org

Nurse practitioners can improve seriously ill patients’ access to crucial advance-care planning services.

In Oregon, nearly 25,000 – about 11 percent – of the Physician Orders for Life-Sustaining Treatment (POLST) forms submitted in the last five years were completed by an advanced practice registered nurse instead of a doctor, according to new research published in the Journal of Palliative Medicine. In 2010, nurses were responsible for signing nine percent of POLST forms.

Nurse practitioners often serve as primary care providers and important members of medical teams caring for patients in their last months of life, when they are most vulnerable and likely to seek end of life treatment counseling. These nurses have been able to enter forms in Oregon’s POLST registry since 2001.

“It is vital that the next generation of physicians honor and champion the role that nurse practitioners play in patient-centered care at the end of life,” said lead researcher Sophia Hayes, a third-year student in the Oregon Health and Science University’s School of Medicine, in a statement to Life Matters Media.

Dr. Susan Tolle

Dr. Susan Tolle

Developed by OHSU medicine professor Dr. Susan Tolle in the 1990s, POLST allows people to make clear what medical treatments they desire or wish to avoid. Patients may indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes, among other things. They also indicate the location where they prefer to receive care. The hope is that patients with this medical order will have their end of life care wishes honored.

Out of 19 states with established POLST programs, only three – Georgia, Louisiana and New York − do not authorize nurse practitioners to sign the orders. The National POLST Paradigm Task Force recommends that physicians, physician assistants and advanced practice nurses be permitted to execute POLST forms. The Centers for Medicare and Medicaid Services supports this recommendation with billing codes for its goals of care counseling reimbursement.

The number of physicians trained in hospice and palliative medicine is thought to be grossly inadequate to meet the needs of the graying U.S. population. According to the study, the inclusion of nurse practitioners in the advance care planning process will become increasingly important.

“This is the future of health care, more team-based care,” Tolle told LMM. “Patients who have a need to talk about their goals will have enough people to respond quickly, because people often complete POLST forms in the last two months of life.”

POLST.001Tolle said there are no disadvantages to having a trained, licensed nurse practitioner sign a POLST form instead of a doctor. Such forms should be completed only after meaningful conversation between the patient, medical professionals and loved ones.

Frequently, the nurse-patient relationship may be the most suited for such a meaningful conversation. According to the paper, “A relationship with continuity is the ideal context for discussing goals of care that may lead to POLST completion in seriously ill patients. APRNs may have that relationship with a patient more than other clinicians.”

Paul Capell’s wife Pamela was diagnosed with a glioblastoma two years ago in Oregon. As her brain tumor progressed, a nurse practitioner helped them complete – and understand – the POLST.

“She and I believed that we are ultimately responsible for our health care decisions and what treatments we get,” Capell told LMM. “The POLST allowed us to ensure that when the time came, there would be no extraordinary life-saving measures on her behalf.”

Pamela died this year, while receiving hospice care at home.

“She did not want to be kept alive and suffer,” Capell said. “She lived a very full, good life. It was very important that she was not kept alive in a hospital bed where she was not aware of what was going on around her.”

– Photo courtesy WikiMedia Commons