Know legal differences between DNAR, POLST when counseling families about end-of-life care

Emily is a 15-year-old girl with end-stage cystic fibrosis (CF). You have cared for Emily as the medical home since she was born. Emily and her parents fully understand her prognosis. During her last hospital admission for a CF exacerbation, Emily and her family asked that a Do Not Attempt Resuscitation (DNAR) order be entered. This was supported by Emily’s pulmonologist. Emily and her parents agree they do not want aggressive resuscitation such as intubation and chest compressions. They are worried that well-meaning health care providers might try to resuscitate Emily against their wishes. How can you help?

General pediatricians increasingly are caring for children with complex medical conditions, including those with terminal illnesses. Although subspecialists frequently follow these children, the physician in the patient’s medical home usually has the strongest connection with the child and family and is well-suited to discuss end-of-life care, including DNAR orders. When developmentally appropriate, the child should be part of these conversations.

DNAR orders have been utilized for more than 40 years. Historically, these documents have been institution-limited, meaning they only covered the patient while in a single setting (e.g., a specific hospital or long-term care facility). Thus, a patient’s nursing home DNAR order might not be recognized at the local hospital. Further, it was common that emergency medical service (EMS) providers did not recognize the order.

The Physician Orders for Life-Sustaining Treatment (POLST) was created to remedy this situation. Known by a number of different acronyms, including MOLST (Medical Orders for Life-Sustaining Treatment) and POST, the POLST is a portable set of written provider orders that memorialize the patient’s or family’s treatment limitations. Because it is recognized under state law, a single document can be used across institutions, eliminating the need to re-execute a DNAR order for multiple health care settings. Further, the POLST makes the patient’s and family’s instructions clear in non-inpatient settings where heath care workers, such as school nurses or EMS, may encounter the patient. This is particularly important in pediatrics because health care workers may be reluctant to limit life-sustaining interventions for a child.

A POLST typically is used for patients with known and identified life-limiting conditions. It is not an advance directive (a legal document specifying what medical interventions a patient may or may not desire if he or she is unable to make medical decisions) or a medical power of attorney (a legal document establishing a surrogate decision-maker for the patient). In pediatrics, advance directives and medical powers of attorney are uncommon and usually unnecessary because children almost always have a parent or guardian who is legally empowered to make medical decisions on their behalf.

Although the actual forms vary from state to state, the POLST generally addresses two major issues. The first is whether the patient will receive CPR in the event of cardiorespiratory arrest. The second is the opportunity to delineate specific therapies to be provided in medical situations other than cardiac arrest. This may be full treatment, limited treatment or comfort measures only. If limited treatment is preferred, specific measures are identified on the form, such as medically administered hydration and nutrition, use of antibiotics, intubation and non-invasive mechanical ventilation. There is a place to sign, but many states do not require the patient or surrogate to sign, only that informed consent is obtained.

The POLST document is maintained with the patient. Like a DNAR order, it can be modified or revoked at any time, including during an emergency or life-threatening event. Typically, it is reviewed with the patient/family when the patient moves from one medical venue to another as well as at regular intervals (some states require these reviews). For inpatient admissions, the admitting team may need to enter the POLST instructions into the hospital’s electronic medical record.

A majority of states have adopted POLST laws, but they vary. Importantly, POLST laws do not apply to children in a small number of states. Further, not every state recognizes an out-of-state POLST form. It is advisable to know the law in the state where you practice.

If a child has a POLST, it is important to communicate with his or her school to avoid misunderstandings. For further guidance, see the AAP policy statement Honoring Do-Not-Attempt-Resuscitation Requests in Schools, http://pediatrics.aappublications.org/content/125/5/1073.full, and the National POLST Paradigm website, www.polst.org.

After a thorough discussion of their concerns, Emily and her family executed a POLST. In addition to the DNAR, they were able to delineate what other measures will be employed when Emily’s condition deteriorates, including opioids for potential air hunger and non-invasive ventilation. Emily’s parents discussed the form and implications with Emily’s school nurse and principal. Emily’s parents and her physician also discussed the POLST with the local EMS service.

Take-home points

• Children with complex and terminal medical conditions are being cared for increasingly by general pediatricians.
• The medical home is an ideal location to discuss end-of-life concerns.
• End-of-life discussions should include the child when developmentally appropriate.
• POLST is a written set of provider medical orders kept with the patient. These orders apply to both inpatient and outpatient settings and include EMS.
• POLST allows patient and family wishes regarding treatment limitations to be respected.
• POLST laws are state-specific. It is important to know your state’s POLST laws.

Dr. Bondi is a member of the AAP Committee on Medical Liability and Risk Management. Dr. Palumbo is a pediatric intensivist and palliative care physician at University of Rochester Medical Center.