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Judy Thomas, JD
By Judy Thomas, JD
Chief Executive Officer
April 1, 2020


If not now, when?

COVID-19 is putting older individuals and those with serious pre-existing medical conditions at high-risk for becoming critically ill very quickly. 

Now is the time for healthcare providers to engage patients in thoughtful conversations about serious illness care.  As our health systems prepare for (or are now dealing with) waves of COVID-19 patients, clinicians at all levels of care can do their part by adding these items to their check-lists:

Do Now

  • Engage seniors and medically fragile patients and their families in conversations about medical treatments during serious illness.
  • Encourage patients or their surrogates to express their wishes and complete appropriate documents. Individuals who are relatively healthy should be encouraged to complete an advance directive.  Individuals who are chronically or seriously ill should be encouraged to complete a POLST.  
  • If advance care planning documents are already in place, conduct a review to be sure that the information is still valid and up-to-date. 

We can support our patients, their families and the health care system as a whole by encouraging all patients to talk about advance care planning in light of COVID-19.  Talk with patients about:

  • Potential serious complications from COVID-19 and how the patient’s age and/or health issues might be a risk factor
  • The treatment options most commonly employed for those who become seriously ill from COVID-19
  • How the patient’s current age and underlying health condition might impact the potential success rate of treatment options like ventilator support
  • The individual’s personal  values, goals and wishes regarding medical care if they were to become seriously ill from COVID-19
  • Whom the patient trusts to make medical decisions for them if they can’t speak
  • The options for keeping the patient comfortable if they decide they do not want to be transported to the hospital or treated with a ventilator
  • The availability of palliative care services and hospice to help ensure comfort and dignity will be a primary goal of treatment

Advance Directive vs. POLST

Once the conversation is had, completion of either an advance health care directive (AHCD) or POLST helps to ensure the patient’s wishes will be recognized and honored.  Make sure to use the form(s) appropriate for the patient.

  • An Advance Directive (also known as an Advance Health Care Directive) can be completed by anyone age 18 or over, and serves one or both of these functions:
    • Durable Power of Attorney for Healthcare (to appoint a health care agent)
    • Instructions for Health Care (to indicate your wishes)
  • POLST (Physician Orders for Life-Sustaining Treatment) is a medical order specifically designed for people who are elderly, seriously ill or medically frail. 

While AHCDs and POLST have many similarities, there are several key differences.

AHCD

  • Appropriate for anyone age 18 or older
  • Provides general instruction for medical treatment
  • Must be signed by the individual and two witnesses or a notary

POLST

  • For seriously ill/frail, at any age
  • Actionable medical orders that transfer across care settings
  • Must be signed by the individual or their medical decisionmaker AND a physician, nurse practitioner or physician assistant

Choices and Challenges

While COVID-19 may help increase  people’s willingness to engage in advance care planning conversations, it also creates logistical challenges that must be overcome, such as having quality conversations using telephone or video calls, completing POLST and other ACP forms and obtaining required signatures in a timely manner.

The need for social distancing during COVID-19 creates challenges to obtaining physical signatures for advance directives and POLST.  Forms can be mailed back and forth, but when the need is urgent, a verbal signature from the patient/decisionmaker is permissible for POLST in accordance with facility/community policy. CCCC is currently seeking guidance or waivers regarding the witness requirements for advance directives.  Best practice for POLST is to carefully document the conversation with the patient/decisionmaker, and write something similar to “Verbal Consent of (patient/decisionmaker)” on the POLST’s Patient/Decisionmaker signature line with an annotation by the MD/NP /PA which says “discussed via phone on  (date)”  then initialed.  A detailed documentation of the phone call on a separate sheet can also be attached.   

Some healthcare providers may be hesitant to honor a POLST without a physical signature, so every effort should be made to replace the “verbal consent” POLST with one that has physical signatures as quickly as possible.  Most patients and families have access to printers and can scan a printed, signed POLST with a smart phone and return it.


Take Action Now!

In the weeks and months ahead, hundreds of thousands of people will become seriously ill due to COVID-19. We will be unable to provide person-centered care if we don’t know what patients want. It is important that we take action now.

Community Outreach – Health systems, insurers and community service providers should reach out to seniors and those at risk of serious illness to provide encouragement and support for completing advance care planning documents.

Assisted Living Communities – Make information on advance care planning and COVID-19 available to residents and encourage residents to talk with their doctor about care plans.

Skilled Nursing Facilities – Engage all patients or their decision makers in care planning for COVID-19, focusing initially on patients at highest risk. Existing advance care planning documents should be reviewed.  A care plan that includes do-not-transfer orders, and orders for medication to promote palliation and supportive care should be in place for those residents who do not want to be transferred to acute care.


Key Reminders

  • POLST is not appropriate for everyone. Younger, healthier people are best served by completing an advance directive and naming a trusted decisionmaker instead.
  • For consumers, filling out an advance directive or POLST is always voluntary and should not be a requirement for admission to a health facility or other congregate living setting.
  • An advance directive must be signed by two witnesses or a notary. If the person lives in a skilled nursing facility, the advance directive must also be signed by the facility’s patient advocate or ombudsman.
  • The POLST is not considered valid until it is signed by a physician, nurse practitioner or physician assistant AND the patient or his/her decisionmaker.
  • Include families and other loved-ones in the conversations whenever possible to avoid future stress or disagreement.
  • Advance directives and POLST should be easily accessible in case of emergency.
  • While POLST is typically printed on bright pink paper, black and white photocopies and scans of POLST are legally valid. There are many advance directive forms, and any one that is appropriately executed is valid.

Resources and Links

Over the past 20 years, the Coalition for Compassionate Care of California has developed and made available a variety of high-quality tools and training programs to support quality conversations around serious illness and the creation of advance directives and POLST.  We’ve gathered many of these resources from CoalitionCCC and CAPOLST, as well as tools from our partners and friends, in one location – our COVID-19 Conversations Toolbox  –  for easy access. We will continue adding information as it becomes available.


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