How to tell the difference between the original POLST form and the 2017 Revision
Both forms have a number at the bottom. The last two digits are the year. Therefore, the earlier form is 111013 and the one approved in 2017 is 090817. In addition, the original POLST does not have a separate Artificial Hydration and Nutrition section (Section C), nor a decisional capacity section (Section D).
Nevada’s Emergency Medical Services (EMS) are an integral and critical partner in the POLST program. EMS is vital to the success of POLST and the integrity of our health care community’s duty of care. The coordinated efforts of patients, their loved ones, our health care facilities’ providers and EMS will assure that patient’s treatment wishes, as expressed on their POLST form, will be honored.
Instructions using the new form #090817 - Five Steps for EMS
Whether responding to a patient in a health care facility or in their home, proceed as follows:
- Ask whether the patient has a POLST form and if in a home, look on the refrigerator or next to the bed (patients are instructed to place their POLST form in either of these two locations).
- Check Section E. Verify it is signed and dated by a healthcare provider (A) and that (B ) or (C) is signed and dated. If so, it is a valid, legal POLST order and should be honored.
- If the patient is in arrest, follow orders in Section A.
- If the patient is not in arrest, consult Section B, which will direct what level of treatment the patient wants.
- If transporting the patient, EMS personnel should take the patient's POLST form with them and present it to the next facility.
POLST is to be Honored … It's the Law
Unlike an Advance Directive, the POLST is a medical order that is to be honored by any provider of health care who treats the patient in any health-care setting, including, without limitation, the patient’s residence, a health care facility or the scene of a medical emergency (NRS 499.694.4.).
The Nevada state-issued DNR identification is still valid but is no longer required; the POLST form is a newer DNR order designation.
In addition, regardless of authority, a provider of health care shall comply with a valid POLST form, regardless of whether the provider of health care is employed by a health care facility or other entity affiliated with the physician who executed the POLST form (NRS 499.695.1). Therefore, the medical director of a Nevada EMS shall comply with a valid POLST regardless of whether that medical director signed and dated the POLST and shall furthermore direct EMS responders to honor the medical orders in Sections A, B, and C of the POLST form.
In other words, Nevada law states that EMS shall honor the medical orders established in Sections A, B, and C of a POLST regardless of setting, unless the POLST is not signed and dated (required for validation) by a physician, APRN or PA and the patient, their representative or surrogate decision-maker in Section E.
What do I do with the information in Section B
If "Full Treatment" is checked, all reasonable measures to sustain life should be attempted.
If "Selective Treatment" is checked, transfer may be appropriate. Follow treatment parameters described in that section. If transferred, take the POLST form with you.
If “Comfort-Focused Treatment” is checked, then the patient should stay where they are, not be transferred and all measures should be taken to make them comfortable. Assure the family or loved ones that this is what the patient wanted and if there are processes that may be disturbing to the family, explain what is being done and why. If comfort cannot be achieved at the patient’s location, they may be transferred to a facility that can manage their comfort. In this case, be sure to take the POLST form with you and present it to the receiving facility.
Who may override a POLST order?
If the patient has decisional capacity, only the patient may change or override the POLST.
If the patient lacks decisional capacity, the following legal representatives may make any changes they wish to a POLST:
- The patient's Durable Power of Attorney for Health Care (aka DPOA-HC or Agent)
- A legal guardian
- The parent of a minor
If the patient's POLST is signed by a surrogate, the surrogate may only make changes to or void a POLST that they themselves completed for the patient (their signature is on the last line of Side 1). A surrogate is any of the following, but only has authority, in the following order, if a legal representative (DPOA-HC, legal guardian or parent of a minor) is not available:
- Spouse
- A majority of the adult children of the patient, who are available
- Parents of an adult
- A majority of the adult siblings of the patient, who are available
- The nearest other adult relative of the patient, by blood or adoption
- An adult who has exhibited special care or concern, for the patient, is familiar with the values of the patient and is willing and able to make health care decisions for the patient
What if someone at the scene objects to the POLST orders?
What has proven effective when anyone objects to a POLST completed by the patient is to explain that the POLST was completed with the patient while they had decisional capacity, they discussed the choices with their health care provider and decided what treatment they wanted in an instance as has occurred. Explain that this may have been one of the very last decisions the patient was able to make, and ask if the person who is objecting is comfortable overriding this last wish.
What happens if a patient’s POLST conflicts with their AD or DNR Identification?
The most recent and valid document should be honored.
What constitutes a valid POLST?
Nevada law establishes that a valid POLST must be signed and dated by a health care provider and by the patient or their representative or surrogate (see the first item under Instructions, above). If a POLST is not both signed and dated as required, then it is not valid and treatment should be determined by best practices.
What if a patient’s POLST is from another state?
All states now have programs similar to Nevada’s POLST. Some have other titles: POST, MOST, MOST, COLST, etc., but all share the feature of establishing patient’s wishes as medical orders to be honored across health care settings. Nevada law provides for EMS to honor an out-of-state POLST program form (NRS 449.696).
See POLST NRS 449.691-697 for more detail regarding Nevada law and the Nevada POLST program.
Can I be prosecuted if there is another AD that I don’t know about?
NRS 449.6952 establishes that a provider of health care may assume the validity of a POLST form unless he or she has knowledge to the contrary and cannot be prosecuted if they have no knowledge of a POLST form.
A provider of health care is not guilty of unprofessional conduct or subject to civil or criminal liability if that treatment complies with a valid POLST form, provider of health care is unaware of the existence of the POLST form or in good faith believes that the POLST form has been revoked, or the patient, their agent as established in a Durable Power of Attorney for Health Care (DPOA), parent of a minor or legal guardian of the patient revokes the POLST (NRS 449.6948).
Does death resulting from compliance with the POLST constitute suicide or homicide?
Death that results when emergency care or life-sustaining treatment has been withheld pursuant to a POLST does not constitute a suicide or homicide (NRS 449.6954).
What if a patient is pregnant?
Life-sustaining treatment must not be withheld or withdrawn regardless of the medical orders of a POLST form, if the patient is known to the attending physician, APRN or PA to be pregnant, so long as it is probable that the fetus will develop to the point of live birth with the continued application of life-sustaining treatment (NRS 449.695.4).