By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Be brave enough to start a conversation that matters.“
-Margaret Wheatley

If a surgeon took a patient with a large colon cancer to the operating room against the previously expressed wishes and consent of a patient, they would be subjected to hospital peer review, investigation by the Medical Board, and potential loss of license to practice medicine.

However, failure to have a goals-of-care conversation, leading to an incorrectly completed POLST, that then leads to a seriously ill patient receiving unwanted CPR/intensive care, almost never results in a referral to peer review or the Medical Board.

It will take a big culture shift for this to change, but perhaps we can learn something from surgeons: using a systematic process. Surgeons have a standard way of documenting a procedure, which is essentially a checklist reflecting the standard of care:

1. Procedure performed
2. Date and time of the procedure
3. Name of surgeon/assistants
4. Indication for procedure
5. Pre-operative diagnosis
6. Post-operative diagnosis
7. Anesthesia
8. Narrative Description of the Procedure
9. Findings
10. Specimens
11. Sponge and needle counts
12. Drains left in after surgery
13. Disposition/Status of the patient

A goals of care conversation with a patient and the family should be documented like a procedure, with a few adaptations.

The Physician Order for Life Sustaining Treatment (POLST) was established by AB 3000, passed in 2008, and took effect in 2009. Early on, the California Healthcare Foundation and the Coalition for Compassionate Care of California funded and organized local community coalitions to educate clinicians, emergency medical technicians, and the public, on how to use the POLST appropriately.

For the patient’s wishes around intubation, CPR and artificial nutrition to be honored, the following steps must occur:

1. A clinician needs to have a goals-of-care conversation with the patient and potentially their family.
2. When appropriate, a POLST form must be filled out correctly, without missing signatures or inconsistent directives.
3. The POLST form must be available to any EMS responding to an emergency call.
4. The family needs to understand and respect the orders expressed in the POLST (or they may hide the POLST or direct the care team to ignore the POLST).
5. The emergency medical technicians, emergency department physicians and ICU physicians must understand what a POLST is, how to read the POLST, what it means, what the legal requirements are, and agree to following the directives expressed in POLST forms.
6. The POLST form must be available to the emergency department physician and potentially the ICU physician caring for a patient who is unable to express their own wishes.

A number of organizations in California are piloting electronic POLST forms and POLST registries. One key finding from these pilots is that there are problems with every one of these six steps, such that many patients are not having their wishes honored by one or more providers.

To focus on just the first two steps, which impact you, our primary care providers: Data from the Palliative Care Quality Network shows that PHC contracted palliative care providers in the PHC service area have a high rate of appropriate use of POLST forms.

However, palliative care clinicians often encounter patients who have a POLST form completed by a non-palliative care clinician which have internal inconsistencies or errors, and in which no goals of care conversation is recorded in the medical record.

This sometimes leads to care that is inappropriate and unwanted.

Consider asking your clinicians to document a goals of care conversation like they would document any other medical procedure. See VitalTalk for some resources that can help.