Reply To: Pediatric POLST

  • Deborah Lafond

    September 22, 2014 at 9:01 am

    We do use the POLST or MOLST (similar and state dependent) here in the DC area. The form can be completed by either an MD or APN depending on the state.  Usually on the POLST form instructions it states who can fill out the form.  We have a discussion with the parents/guardians and the child (if age and developmentally appropriate) in a stepwise fashion, following the famliy’s ability to engage in these difficult discussions. 

    1.  People involved –  Most of the time the POLST is completed by our palliative care team, with the collaboration of the primary oncology team, but sometimes the primary oncology team is the ones filling it out. We are very sure to engage the primary social worker and/or psychologist. If a family is not ready to discuss the POLST, in some circumstances our home hospice partners continue the discussion after discharge.  We never make the POLST a condition of discharge or hospice referral.  If a family wants a full code, then we respect that and note that accordingly on the POLST form, however, as the child’s clinical condition changes at home, often the hospice can further explore goals of care.

    2.  Timing –  If it is an older child, adolescent or young adult, we try to start the discussion with an advanced directive such as My Wishes, Voicing My Choices or Five Wishes (age dependent).  The POLST is the last part of the process.  By the time we have gotten to the POLST, there have been a series of discussions with the family and child regarding their goals of care.  Of course. sometimes these discussion have to happen more rapidly because of the clinical condition of the child, but we try to take our timing from the family’s readiness to have these discussions.

    3.  Topics addressed – These are usually pretty well laid out on the POLST form, depending on the state, of the minimum discussion points.  We are sure to address code status, artificial ventlation (intubation but also BiPAP/CPAP), artificial fluids and hydration, returning to the hospital for care, transfer to the ICU, medical work-up (how invasive to go), antibiotics (including fever criteria and any changes to the oncology routine given goals of care) tranfusion parameters (if any changes from goals of care) and dialysis.  Other topics are dependent upon the trajectory of the child’s disease and specifics for that family. 

    4.  After the form is completed – We give the original form to the family with several copies, so they can provide them to their PMD or other folks involved in the care at home.  Be sure to have copies for both parents or anywhere the chld might go other than the home, i.e. school, daycare, other parent’s home, grandparent’s home, etc.  We also send a copy to medical records, a copy to our medical transport team (who then in turn routes a copy to the child’s local EMS providers), a copy to the primary oncology team (we ask them who wants to be the keeper of this form and it is the social worker), and the palliative care team keeps a copy.  We have the Cerner system EMR, so we also make sure that a note is written which outlines the discussion and the POLST form wishes of the family and where copies can be located.

    If you have another system that works better, we are always up to learn better ways to make this work!  I look forward to seeing the discussion unfold.  You may also want to post this on the Palliative and End of Life discussion forum.

    Thanks, Debbie

    Deborah Lafond
    Children’s National Medical Center
    Saint Leonard, MD
    United States

    Original Message:
    Sent: 09-22-2014 05:53 AM
    From: Rima Saad
    Subject: Pediatric POLST

    This message has been cross posted to the following Discussions: Advanced Practice Nurses and APHON Open Forum .

    I would like to ask if anyone is using POLST in pediatrics. It would be great if you can elaborate  on the process (people involved, timing, topics addressed) and send the form.

    Looking forward for your replies.

    Rima Saad
    Clinical Nurse Specialist
    American University of Beirut