Physician Orders for Life-Sustaining Treatment (POLST)

The Coalition for Compassionate Care of California is the home for POLST in California.

POLST (Physician Orders for Life-Sustaining Treatment) is a medical order signed by both a patient and physician, nurse practitioner, or physician assistant that specifies the types of medical treatment a patient wishes to receive toward the end of life. POLST is a tool that encourages conversation between providers and patients about their end-of-life treatment options, and helps patients make more informed decisions and communicate their wishes clearly. As a result, POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, and help ensure that patient wishes are followed.

Download the POLST form, tools, and resources at www.caPOLST.org.

Learn more about National POLST at polst.org.

An Overview of the Coalition for Compassionate Care of California’s (CCCC) POLST Implementation Initiative

Implementing Physician Orders for Life Sustaining Treatment (POLST) in a state as large and diverse as California is a formidable task. Despite many barriers, however, use of POLST has spread throughout the state – due in large part to CCCC and volunteers in 27 local coalitions.

CCCC and its partners spread POLST in one of the largest, most diverse states faster than any other state in the country. Within the first five years, California had legislation establishing POLST in state statute, 27 community-based coalitions working on POLST at a local level, a standardized two-day curriculum on the POLST conversation, a statewide taskforce of stakeholders, a website, and educational materials in a range of languages. By 2012, 95% of California nursing homes had completed POLST forms with residents, 65% of hospitals had a formal POLST policy, and 75% of assisted living facilities had implemented POLST education for staff.

The successful implementation of POLST is the result of CCCC’s unique ability to bring together people with a passion for advance care planning, and spark ideas into action through collaboration and the growth of community-based coalitions. The following is a brief overview of CCCC’s activities and accomplishments that have helped make POLST a reality in California.

Establishing POLST

Sponsored the legislation which established POLST in California. AB 3000, authored by then-Assembly Member Lois Wolk, was passed unanimously and went into effect January 1, 2009.

Developing and Improving the POLST Form

Developed the official California POLST form in collaboration with the California POLST Task Force and California Emergency Medical Services Authority. The form went into effect January 1, 2009.
Co-sponsored successful legislation (AB 637/Campos) which authorizes nurse practitioners and physician assistants – under the supervision of a physician and within their scope of practice – to sign POLST forms and make them actionable medical orders. The bill went into effect on Jan. 1, 2016.
Translated California’s POLST form into Armenian, Chinese, Farsi, Hmong, Japanese, Korean, Pashto, Russian, Spanish, Tagalog, Vietnamese, and Braille.
Leads a semi-annual process to revise the POLST form, including the review of hundreds of suggested changes. The POLST was revised in 2011, 2014, and again in 2016. With each revision, CCCC developed educational materials to support a successful rollout of form revisions.

Strengthening POLST through a Statewide Infrastructure

Coordinates and staffs the following committees and workgroups made up of stakeholders from throughout the state:
- Statewide POLST Task Force: The POLST Task Force includes representatives from a broad variety of stakeholder groups which are key to the success of POLST. The Task Force provides guidance and input on all aspects of POLST that have statewide implication, including public policy, changes to the form, and dissemination of information.
- POLST Documentation Committee: Provides input on the POLST form itself, evaluating potential changes and updates.
- POLST Physician Leadership Council: Includes physicians, nurse practitioners (NPs), and physician assistants (PAs) who are actively involved in local POLST coalitions across the state. This group provide input into the development of physician educational materials and guidance on POLST education to physicians, NPs, and PAs.

Supports 27 local POLST coalitions throughout California. Activities include:
- Organizing and hosting in-person meetings of POLST coalitions
- Providing speaker training to local POLST coalition leaders
- Facilitating monthly coalition calls

Serves as a central clearinghouse for questions from consumers, providers, and the media.

Educating Healthcare Providers About POLST

Developed a two-day standardized train-the-trainer POLST curriculum, which is highly-interactive and focuses on facilitating quality, compassionate POLST conversations. The curriculum is comprised of seven core modules, a Trainer Toolkit, and numerous resources.
Educated over 950 POLST trainers to date throughout California through train-the-trainer curriculum.
Hosts quarterly POLST trainer support calls.
Provides a one-day workshop on facilitating POLST conversations
Developed a POLST seminar for pediatric care teams.
Present on POLST at numerous local, statewide, and national conferences.

Developing Tools and Resources

Developed and maintains online resources, including: www.caPOLST.org where all materials are available for free to healthcare providers and consumers
Developed education materials, including:
- POLST consumer and provider brochures
- Frequently Asked Questions (FAQs) for consumers and provider groups
- POLST information cover sheets for use in nursing homes and residential care facilities for the elderly
- Quick Reference for Physicians
- Quick Reference for Skilled Nursing Facilities
- Decision Guides for Health Care Providers on Life Sustaining Treatments
Developed model POLST policies and procedures for:
- Acute Care Hospitals
- Skilled Nursing Facilities
- Hospice
Developed educational and information videos, including:
- The POLST Conversation, a training video that includes eight vignettes and a companion discussion guide
- A POLST video which aired on UCTV highlighting how POLST travels across the continuum of care.
- A POLST at Work video that explains how POLST works for consumers and providers
Developed a POLST Quality Assurance and Performance Improvement (QAPI) Toolkit to assist skilled nursing facilities in implementing and evaluating POLST programs.

Supporting Quality Implementation

Successfully lobbied for questions about POLST to be added to MDS 3.0, allowing CCCC to monitor use POLST in California in nursing homes.
Conducted two surveys to determine POLST utilization in nursing homes. By 2012, 72 percent of nursing homes reported admitting a resident with a POLST form, and 95 percent reported that staff members had completed a POLST with a resident.
Conducted a survey to determine POLST utilization in hospitals. One survey showed that almost 95 percent of California hospitals have admitted a patient with a POLST, and most hospitals have policies in place to address POLST.
Developed survey on POLST penetration and use in the assisted living setting, which found that 85 percent of facilities had a specific place to keep the POLST form where it could be retrieved if necessary. Another survey of local emergency services authorities found that most emergency medical personnel had received education concerning POLST and recognized how to incorporate the content of the document into care in the field.
Developed tools and process for assessing the quality of POLST form completion in nursing homes, including a POLST Quality Assurance and Performance Improvement (QAPI) Toolkit.
Conducted quality audits of POLST form completion in 30 nursing homes throughout California in 2010 and re-audited the facilities in 2011. The audits uncovered several opportunities for improvement in the quality of the conversation, how the forms are completed and how the forms are transported.

Expanding POLST Awareness

Developed clear, concise messaging on POLST that can be used throughout the state.
Regularly engages the media in efforts to expand awareness and use of POLST.
Regularly communicating news and information about POLST to over 5,000 subscribers through CCCC’s online e-newsletter and web blog.

Championing an Electronic POLST Registry

Leading efforts to make POLST available electronically across settings through a statewide registry, health information exchanges, via QR codes, and other technological advances.
Co-sponsored successful legislation (SB 19) which requires the California Health and Human Services Agency to establish and operate a California POLST eRegistry Pilot to collect POLST and disseminate the information to authorized users, including healthcare providers.
Developed report on the status of electronic POLST registries nationally.
Working with California Health Care Foundation (CHCF) to educate decision-makers about the importance of a POLST registry, and participated in a December 2014 POLST Registry Legislative Briefing hosted by CHCF

Helping to Lead the National POLST Effort

Regularly share knowledge, resources and trainings with groups in other states which are developing POLST programs.
Serve in leadership positions on National POLST Task Force.
Hosted a National POLST Conference in February 2012, attended by more than 200 participants.
Participate regularly in the National POLST Sustainability, Communications, Technology and Registry Committees.