Hospice and the Pennsylvania Orders for Life Sustaining Treatment — POLST

Published on January 6, 2023

Updated on November 25, 2023

A of the implications of each choice for the terminally ill patient as well as the loved ones of those who are terminally ill. This form comes into practice typically under two conditions… no pulse and is not breathing OR has a pulse and/or is breathing (but while not mentioned is typically in the last two weeks of life if no measures are taken with the understanding that any and all measures do not guarantee a longer time frame). Let's the form below:

Pennsylvania Orders for Life Sustaining Treatment (POLST)

“A” — check one: CRP/Attempt Resuscitation. This area states attempt because CPR does not guarantee success! Even for the healthy, the success rate for CPR is extremely low! In the hospital setting surrounded by doctors, nurses, nurse aides, therapists, other patients and families, the success rate is twenty percent survival rate with eighty percent of those who survived having some type of health status change in a negative direction which for some people can be lifelong disability. In a nursing home setting as well as the private home setting, the success rate drops to around two percent.

The process of CPR involves a purposeful violent attempt to restart the person's heart and often involves fractured ribs that have the potential to damage other organs.

The other choice is DNR/Do not attempt Resuscitation (Allow Natural Death). This is often the preferred choice for anyone who is terminally ill and on hospice because the goal of hospice is through the end-of-life journey without the purposeful intent to slow things down OR speed things up. This also means a death with dignity vs. a violent procedure to try and restart the heart which fails most of the time.

“B” Medical interventions (DNR does not equal do not treat). This is the section that is intricately connected to “A” in practice. IF “CRP” was attempted and is successful, then typically the choice is limited additional interventions or full treatment. Both often involve going to the hospital. While some nursing facilities can provide IV fluids (extremely dangerous at end of life with a high potential to cause your loved one to suffer), most nursing facilities do not provide cardiac monitors or advanced treatment that would be included in full treatment.

Comfort measures only typically go with DNR as the goal is to allow peaceful passing. Pennsylvania does allow for ala cart choices where a patient, power of attorney and the like can check attempt CPR and then use comfort measures only; but keep in mind the result from a practical standpoint is commit extreme violence against the person's body in attempt to restart the heart, then provide comfort for the damage done. This is counterproductive from a hospice philosophy point of view because the entire goal is comfort…

Sections “C” and “D” can occur at any time prior to death with “D” often being brought up in the last two weeks of life.

Section “C” . The first choice can lead to extremely painful and uncomfortable situations if the patient develops sepsis where hospice pain medications may only be partially effective. The second choice provides the most comfort for the patient. The third choice from a practical sense never makes sense because “if life can be prolonged” cannot be guaranteed by anyone.

Section “D” Artificially administered hydration and nutrition deal with the dignity of allowing the patient to say they are not hungry or thirsty and avoid being forced nutrition artificially as well as to pass naturally. That's the first check box (nothing artificial). The second choice is a nasogastric tube that is inserted into the patient's nostril and down into their stomach which is an extremely uncomfortable procedure to have done; and then there's a trial of hydration and nutrition so see if the patient tolerates it as evidenced by not vomiting up the food, not aspirating on the food, and not going into fluid overload; all of which is potentially extremely painful. The third option is surgery for a feeding tube. While it can be viewed as being more comfortable (since one is sedated for the operation to place the feeding tube), having one is extremely substantial risk for fluid overload, pneumonia, and other problems because there is zero science on how much food a dying person can be force fed.

I'm using blunt language because often the person filling out the form (and this could be the patient themselves) is looking for some hope (i.e. have some chicken noodle soup, and you will feel better) without realizing the ramifications of those choices.

In my experience as a the most comfortable deaths include the following choices:

  • DNR
  • Comfort Measures Only
  • Determine use or limitation of when infection occurs, with comfort as goal
  • No hydration or artificial nutrition by tube (always offer food and liquids by mouth if feasible).

Lastly, always remember this form is not a contract written in stone. It can be changed easily even at the last moment with a call to the appropriate provider.

Resources

DNR and the terminally ill

End-of-Life Decisions: Don't wait until it's too late for advanced directives

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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