What You Need to Know About AB 637 and POLST

Originally posted on October 9, 2015

As of January 1, 2016, Nurse Practitioners and Physician Assistants will be authorized to sign California POLST forms.

Background

Physician Orders for Life-Sustaining Treatment (POLST), which was introduced in California through legislation (AB 3000) in 2008, is a medical order that gives seriously-ill patients more control over their care. Produced on a distinctive bright pink form and signed by both the doctor and patient, POLST specifies the types of medical treatment that a patient wishes to receive at the end of life. In so doing, POLST helps ensure that patients receive the treatment they want and avoid the treatment they don’t want, thereby reducing patient and family stress.

Issue

Under current law, the POLST form must be signed by the patient (or their legal decisionmaker) and a physician to become a valid medical order.

What's New?

Assembly Bill 637, recently signed by Governor Brown, allows nurse practitioners and physician assistants acting under the supervision of a physician and within their scope of practice authorized by law to sign the POLST form. AB 637 goes into effect on January 1, 2016.

Important Facts About the New Law:
 
  • AB 637 goes into effect on January 1, 2016. Any POLST form signed by a NP or PA prior to January 1, 2016, will not be legally valid.
  • Section 4780(c) of the Probate Code has been amended to read:

“The form shall be completed by a health care provider based on patient preferences and medical indications, and signed by a physician, or a nurse practitioner or a physician assistant acting under the supervision of the physician and within the scope of practice authorized by law, and the patient or his or her legally recognized health care decisionmaker.”

  • Only physicians, nurse practitioners and physician assistants can sign the POLST under the new law. POLST signing authority is not expanded to include any other professional classifications.
  • AB 637 does not alter any other existing regulations, codes or standardized procedures and protocols for nurse practitioners and physician assistants in California, including completion of pre-hospital DNR forms.
  • Under AB 637, NPs and PAs are legally authorized to sign POLST forms regardless of whether the patient has chosen DNR or Attempt Resuscitation/CPR in Section A.
Changes to the POLST Form:
 
  • A revised POLST form which includes a signature line for “Physician / Nurse Practitioner / Physician Assistant” on the front and instructions on the back will be available in mid-December 2015 online at caPOLST.org.
  • Best practice is for NPs and PAs to only use the revised POLST form (with an effective date of 01/1/2016). NPs and PAs are advised against signing old versions of the POLST form (with effective dates of 2009, 2011 or 2014) because those versions do not contain the language clarifying the change in law allowing nurse practitioner and physician assistant signature. Signing older versions of the form may cause confusion as to the form’s validity. Ensuring that patient wishes are honored is always our top priority.
  • The POLST form will continue to be called the “Physician Orders for Life-Sustaining Treatment (POLST)” form. The title will not change.
  • A new space has been added to the back of the POLST form to write the name of the supervising physician, in compliance with existing regulations.
  • A supervising physician is not required to counter-sign the form.
Next Steps:
    • The Coalition for Compassionate Care of California (CCCC) will be hosting a free webinar about the POLST changes under AB 637 in November. Many community POLST and advance care planning coalitions will also be offering education and training to get providers ready for the change in law. CCCC will also be working with California Association for Nurse Practitioners (CANP), the California Academy of Physician Assistants (CAPA) and other related organizations to provide information and education. For more information, visit the CCCC website at CoalitionCCC.org or call (916) 489-2222.
    • NPs and PAs who anticipate signing POLST forms after January 1, 2016, should ensure they have a ready stock of 2016 POLST forms available for their use.  Hospitals, health systems and medical practices may be reluctant to discard their existing stock of blank POLST forms.  Once the revised version is approved by the California Emergency Medical Services Authority, a PDF of the 2016 POLST form is expected to be available in mid-December 2015 from caPOLST.org. The form can be downloaded and printed on Ultra Pink cardstock.  Bulk copies will be available for order through MedPass.
    • NPs should ensure that the nurse practitioner standardized procedures (SP) are updated to incorporate the POLST procedure, and that the collaborating physician signs the new SPs.
    The Coalition for Compassionate Care of California (CCCC) has been the lead for POLST in California since the program’s inception. For information, education and resources on POLST and advance care planning, contact the CCCC at (916) 489-2222, or visit CoalitionCCC.org and caPOLST.org.