Oregon POLST Newsletter - July 15, 2020

The Oregon POLST Registry experienced a significant drop in POLST submissions in April and May, as health care professionals began working from home and elective visits were cancelled. However, June submissions were down 14.4% reflecting a trend back to prior pre-pandemic monthly baseline rates. A few health systems and hospice programs continue to struggle with the logistics of POLST submissions during the pandemic, but most are now completing and submitting POLST forms approaching prior levels.

The Oregon POLST Registry has remained fully operational throughout the pandemic, averaging a 3-day backlog to load forms. POLST form order requests are also back to baseline levels, and the POLST Program’s six new educational webinars have had over 4,000 views combined. These videos can be found at: https://oregonpolst.org/covid19.

During the Pandemic Soliciting Feeding Tube Preferences Is Often Seen As Irrelevant

Emergency medical services never found the tube feeding section on the older versions of the POLST form to be useful and formally endorsed its removal (details found here).

In the context of the pandemic, health care professionals talk to patients with advanced illness about preferences related to hospitalization and intensive care. Many HCPs find the issue of feeding tube placement not relevant to decisions that frail elders with advanced heart and lung disease need to make during the pandemic.

A loving mother’s desire to ensure a comfortable and caring death for her dying son serves as a tangible reminder of the POLST Program's purpose in assuring end-of-life wishes are honored.

This story is unique in our portfolio of patient stories, in that it is our first story to relate how EMS was called, but did something differently because of an existing POLST. Usually, POLST guides decisions not to call EMS for those who have chosen to allow a natural death.

In this story, EMS discovers a POLST and quietly withdraws from the scene leaving a dying child to rest in his mother's arms.

Senate Bill 1606 Reminds Us That Patients Should Never Feel Pressured to Complete a POLST Form

It has long been against federal law to require an advanced directive or POLST as a condition of care. For example a nursing home cannot require that a patient completes a POLST form as a requirement for admission to a facility. (Nursing Home Alert details are here.)

Senate Bill 1606 emphasizes that pressuring a patient to complete a POLST form is illegal. The POLST since its inception has always been voluntary. The Oregon POLST Quality Committee has previously identified counting POLST forms, even without financial incentives, as a source of undue pressure (see here for details).

Senate Bill 1606 requires notification of the Case Manager for persons with intellectual or developmental disabilities prior to withholding or withdrawing treatment or referral to hospice. The requirement to notify the Case Manager is new. The Case Manager’s role is to provide information about the person. Case Managers do not make or authorize decisions regarding the withholding or withdrawing of treatment. Specifically, a Case Manager who receives such a notice "shall provide the person giving the case manager notice with any information in the case manager’s possession that is related to the principal’s values, beliefs and preferences with respect to the withholding or withdrawing of life-sustaining procedures."

The “Guidelines on POLST Use for Persons with Significant Disabilities who are Now Near the End of Life” emphasize this role with additional protections. This document is in the process of revision.

Pre-Existing POLST Medical Orders
Are To Be Honored

Oregon DHS issued a policy transmittal in February of 2020. This transmittal clarifies the expectation for direct support professionals who serve individuals in 24-hour residential program settings, when there is a POLST form with a DNR order. This document was written in response to caregivers (direct support professionals) performing CPR on individuals in hospice with DNR orders. This document clarifies the role of POLST in those who are nearing the end of their lives and affirms that POLST medical orders should be honored.