When a terminally ill or frail, elderly patient ends up in an emergency room, heroic life-saving measures frequently cause more harm then good. In such circumstances, modern medicine’s capacity to sustain life in the most extreme cases becomes a source of pain and confusion for these patients. Even when they have expressed their wishes for end-of-life care those wishes can be overlooked, most often because providers know nothing about them.
In the early 1990s medical ethicists began to voice concern over patients’ loss of control near the end of life. In Oregon that concern led to the development of Physicians Orders for Life Sustaining Treatment (POLST) to document individuals’ preferences for end-of-life care and reduce the frequency of unnecessarily mechanical, painful and prolonged deaths. Today POLST is a nationwide paradigm adopted by 16 states and under development in 29 others.
California authorized the use of POLST in 2008 and, through efforts of the Coalition for Compassionate Care of California (CCCC), its use has been widely adopted throughout the state. Despite this broad adoption, however, there continues to be one critical sticking point with POLST: It is paper-based. If the paper POLST document is not physically transferred with a patient who ends up in the ER unconscious or unable to communicate, doctors have no other access to POLST data. In Oregon, EMTs reported that in about 25 percent of cases they were unable to find the physical POLST form. To solve this problem, Oregon established a mandated electronic POLST registry in 2009 that provides both EMTs and ER doctors with immediate access to POLST data via phone. Other states, including New York, are working on similar POLST registries with the additional feature of electronic access to POLST data.
Since 2007, the California HealthCare Foundation (CHCF) has been investigating and investing in replicating Oregon's success for California. In February 2014, the California HealthCare Foundation (CHCF) engaged BluePath Health to conduct an in-depth feasibility study to reach out to these and other health care stakeholders to assess the situation.
During the course of a nine-month effort, BluePath Health consulted with policy and program experts across the country regarding POLST. We also conducted a comprehensive assessment of the legislative and regulatory environment, programs and initiatives that support POLST and lessons learned from other registry initiative, as well as analyzing the stakeholder and technology landscape. In addition to conducting and presenting our research, we also co-authored an issue brief with CCCC summarizing the study’s findings. This brief, "Information in a Heartbeat: Readiness Assessment for Establishing a POLST Registry in California", was published by CHCF in May 2015.
Our work concluded that the success of a California POLST registry depends on legislative action in several areas, from regulatory mandates to health system integration to digital signature validation. Today, thanks to the efforts of the CCCC and Senator Lois Wolk (D-Davis) that legislation is in progress. Bi-partisan Senate Bill 19, which establishes a statewide electronic POLST registry, has passed through California's Senate with a unanimous vote and is now moving to the Assembly. Stay tuned with us on Twitter at @bluepathhealth for more news on California's POLST registry.