CA POLST

[California State Law]
POLST LEGISLATION
AND INTENT

[POLST INTENT:]

LEGISLATIVE COUNSEL’S DIGEST

Existing law defines a “request to forgo resuscitative measures” as a written document, signed by an individual, or a legally recognized surrogate health care decisionmaker, and a physician, that directs a health care provider to forgo resuscitative measures for the individual. Existing law provides that a health care provider who honors a request to forgo resuscitative measures is not subject to criminal prosecution, civil liability, discipline for unprofessional conduct, administrative sanction, or any other sanction, as a result of his or her reliance on the request, provided that he or she meets certain requirements.

AB 3000, Wolk. Health care decisions: life-sustaining treatment.

This bill would make findings and declarations regarding health care planning. The bill would

redefine a request to forgo resuscitative measures as a “request regarding resuscitative measures,”

which would be a written document, signed by an individual with capacity, or a legally recognized health care decisionmaker, and that individual’s physician,

that directs a health care provider regarding resuscitative measures.

The bill would include within this definition a Physician Orders for Life Sustaining Treatment (POLST) form, as specified.

The bill would authorize a legally recognized health care decisionmaker to execute the POLST form

only if the individual lacks capacity,

or the individual has designated that the decisionmaker’s authority is effective,

and would require a health care provider to explain the form, as specified.

The bill would allow an individual having capacity to revoke a POLST form, as specified.

The bill would require a health care provider to treat an individual in accordance with a POLST form,

except as specified,

and would permit a physician to conduct an evaluation of the individual

and issue a new order consistent with the most current information available about the individual’s health status and goals of care.

The bill would require the legally recognized health care decisionmaker of an individual without capacity to consult with the individual’s treating physician prior to making a request to modify that individual’s POLST form,

and would provide that an individual with capacity may at any time request alternative treatment to that treatment that was ordered on the form.

The bill would provide that if the orders in an individual’s request regarding resuscitative measures directly conflict with his or her individual health care instruction, the most recent order or instruction is effective. The bill would also make conforming changes.

SECTION ONE:
The Legislature finds and declares all of the following:

(a) It is important for people to make health care decisions before it is necessary.

(b) Health care planning is a process, rather than a single decision, that helps individuals think about the kind of care they would want if they become seriously ill or incapacitated, and encourages them to talk with their loved ones and physicians.

(c) Advance directives give individuals the ability to put their wishes in writing and to identify the person who would speak for them should they become unable to speak for themselves.

(d) The Physician Orders for Life Sustaining Treatment (POLST) form complements an advance directive by taking the individual’s wishes regarding life-sustaining treatment, such as those set forth in the advance directive, and converting those wishes into a medical order.

(e) The hallmarks of a POLST form are

(1) immediately actionable, signed medical orders on a standardized form,

(2) orders that address a range of life-sustaining interventions as well as the patient’s preferred intensity of treatment for each intervention,

(3) a brightly colored, clearly identifiable form, and

(4) a form that is recognized, adopted, and honored across treatment settings.

(f) A POLST is particularly useful for individuals who are frail and elderly or who have a compromised medical condition, a prognosis of one year of life, or a terminal illness.

POLST LEGISLATION

SEC. 2. The heading of Part 4 (commencing with Section 4780) of Division 4.7 of the Probate Code is amended to read:

   4780.  (a) As used in this part:
   (1) "Request regarding resuscitative measures" means a written document, signed by (A) an individual with capacity, or a legally
recognized health care decisionmaker, and (B) the individual's
physician, that directs a health care provider regarding
resuscitative measures. A request regarding resuscitative measures is
not an advance health care directive.
   (2) "Request regarding resuscitative measures" includes one, or
both of, the following:
    (A) A prehospital "do not resuscitate" form as developed by the
Emergency Medical Services Authority or other substantially similar
form.
   (B) A Physician Orders for Life Sustaining Treatment form, as
approved by the Emergency Medical Services Authority.
   (3) "Physician Orders for Life Sustaining Treatment form" means a
request regarding resuscitative measures that directs a health care
provider regarding resuscitative and life-sustaining measures.
   (b) A legally recognized health care decisionmaker may execute the
Physician Orders for Life Sustaining Treatment form only if the
individual lacks capacity, or the individual has designated that the
decisionmaker's authority is effective pursuant to Section 4682.
   (c) The Physician Orders for Life Sustaining Treatment form and
medical intervention and procedures offered by the form shall be
explained by a health care provider, as defined in Section 4621. The
form shall be completed by a health care provider based on patient
preferences and medical indications, and signed by a physician and
the patient or his or her legally recognized health care
decisionmaker. The health care provider, during the process of
completing the Physician Orders for Life Sustaining Treatment form,
should inform the patient about the difference between an advance
health care directive and the Physician Orders for Life Sustaining
Treatment form.
   (d) An individual having capacity may revoke a Physician Orders
for Life Sustaining Treatment form at any time and in any manner that
communicates an intent to revoke, consistent with Section 4695.
   (e) A request regarding resuscitative measures may also be
evidenced by a medallion engraved with the words "do not resuscitate"
or the letters "DNR," a patient identification number, and a 24-hour
toll-free telephone number, issued by a person pursuant to an
agreement with the Emergency Medical Services Authority.

SEC. 4.  Section 4781.2 is added to the Probate Code, to read:
   4781.2.  (a) A health care provider shall treat an individual in
accordance with a Physician Orders for Life Sustaining Treatment
form.
   (b) Subdivision (a) does not apply if the Physician Orders for
Life Sustaining Treatment form requires medically ineffective health
care or health care contrary to generally accepted health care
standards applicable to the health care provider or institution.
   (c) A physician may conduct an evaluation of the individual and,
if possible, in consultation with the individual, or the individual's
legally recognized health care decisionmaker, issue a new order
consistent with the most current information available about the
individual's health status and goals of care.
   (d) The legally recognized health care decisionmaker of an
individual without capacity shall consult with the physician who is,
at that time, the individual's treating physician prior to making a
request to modify that individual's Physician Orders for Life
Sustaining Treatment form.
   (e) An individual with capacity may, at any time, request
alternative treatment to that treatment that was ordered on the form.

   SEC. 5.  Section 4781.4 is added to the Probate Code, to read:
   4781.4.  If the orders in an individual's request regarding
resuscitative measures directly conflict with his or her individual
health care instruction, as defined in Section 4623, then, to the
extent of the conflict, the most recent order or instruction is
effective.
  SEC. 6.  Section 4781.5 is added to the Probate Code, to read:
   4781.5.  The legally recognized health care decisionmaker shall
make health care decisions pursuant to this part in accordance with
Sections 4684 and 4714.

  SEC. 7.  Section 4782 of the Probate Code is amended to read:
   4782.  A health care provider who honors a request regarding
resuscitative measures is not subject to criminal prosecution, civil
liability, discipline for unprofessional conduct, administrative
sanction, or any other sanction, as a result of his or her reliance
on the request, if the health care provider (a) believes in good
faith that the action or decision is consistent with this part, and
(b) has no knowledge that the action or decision would be
inconsistent with a health care decision that the individual signing
the request would have made on his or her own behalf under like
circumstances.

SEC. 8.  Section 4783 of the Probate Code is amended to read:

 4783.  (a) Forms for requests regarding resuscitative measures
printed after January 1, 1995, shall contain the following:

"By signing this form, the legally recognized health care
decisionmaker acknowledges that this request regarding resuscitative
measures is consistent with the known desires of, and with the best
interest of, the individual who is the subject of the form."

   (b) A printed form substantially similar to that described in
subparagraph (A) of paragraph (2) of subdivision (a) of Section 4780
is valid and enforceable if all of the following conditions are met:
   (1) The form is signed by the individual, or the individual's
legally recognized health care decisionmaker, and a physician.
   (2) The form directs health care providers regarding resuscitative
measures.
   (3) The form contains all other information required by this
section.
  SEC. 9.  Section 4784 of the Probate Code is amended to read:
   4784.  In the absence of knowledge to the contrary, a health care
provider may presume that a request regarding resuscitative measures
is valid and unrevoked.

SEC. 10.  Section 4785 of the Probate Code is amended to read:
   4785.  This part applies regardless of whether the individual
executing a request regarding resuscitative measures is within or
outside a hospital or other health care institution.

POLST FORM

HIPAA PERMITS DISCLOSURE of POLST to OTHER HEALTH CARE PROFESSIONALS as NECESSARY

Physician Orders for Life-Sustaining Treatment (POLST)

First follow these orders, then contact physician. This is a Physician Order Sheet based on the person’s medical condition and wishes. Any section not completed implies full treatment for that section. Everyone shall be treated with dignity and respect.

Last Name

First Name/Middle Initial

Date of Birth

A
Check One
CARDIOPULMONARY RESUSCITATION (CPR):
Person has no pulse and is not breathing.

¨ Attempt Resuscitation/CPR

¨ Do Not Attempt Resuscitation/DNR (Allow Natural Death))

When not in cardiopulmonary arrest, follow orders in B, C and D.

B
Check One

MEDICAL INTERVENTIONS:
Person has Pulse and/or is breathing

¨ Comfort Measures Only Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Antibiotics only to promote comfort. Transfer if comfort needs cannot be met in current location.

¨ Limited Additional Interventions Includes care described above. Use medical treatment, antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care.

¨ Full Treatment Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and defibrillation/cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.

Additional Orders: _________________
________________________________

C
Check One

ARTIFICIALLY ADMINISTERED NUTRITION:
Offer food by mouth if feasible and desired.

¨ No artificial nutrition by tube.

¨ Defined trial period of artificial nutrition by tube.

¨ Long-term artificial nutrition by tube.

Additional Orders: _________________
________________________________

D


SIGNATURES AND SUMMARY OF MEDICAL CONDITION

Discussed with:

Patient Health Care Decisionmaker Parent of Minor Court Appointed Conservator Other:

Signature of Physician

My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condition and preferences.

Print Physician Name    Physician Phone Number    Date

Physician Signature (required)    Physician License #

Signature of Patient, Decisionmaker, Parent of Minor or Conservator

By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form.

Signature (required) Name (print) Relationship (write self if patient)

Summary of Medical Condition

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

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A Check One	CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing. ¨ Attempt Resuscitation/CPR ¨ Do Not Attempt Resuscitation/DNR (Allow Natural Death)) When not in cardiopulmonary arrest, follow orders in B, C and D.
B Check One	MEDICAL INTERVENTIONS: Person has Pulse and/or is breathing ¨ Comfort Measures Only Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Antibiotics only to promote comfort. Transfer if comfort needs cannot be met in current location. ¨ Limited Additional Interventions Includes care described above. Use medical treatment, antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care. ¨ Full Treatment Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and defibrillation/cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care. Additional Orders: _________________ ________________________________
C Check One	ARTIFICIALLY ADMINISTERED NUTRITION: Offer food by mouth if feasible and desired. ¨ No artificial nutrition by tube. ¨ Defined trial period of artificial nutrition by tube. ¨ Long-term artificial nutrition by tube. Additional Orders: _________________ ________________________________
D	SIGNATURES AND SUMMARY OF MEDICAL CONDITION Discussed with: Patient Health Care Decisionmaker Parent of Minor Court Appointed Conservator Other: Signature of Physician My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condition and preferences. Print Physician Name Physician Phone Number Date Physician Signature (required) Physician License # Signature of Patient, Decisionmaker, Parent of Minor or Conservator By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form. Signature (required) Name (print) Relationship (write self if patient) Summary of Medical Condition