Standing orders

tyvin, BSN, RN · Mar 17, 2017

The POLST (provider orders for life-sustaining treatment) should be very clear on what the patient wants/wishes. Let's be clear: it's the patient's wishes. That is why it's so critical for people to have their advanced directives thought out and filled out ASAP (don't wait until you're sick). Everyone should have advanced directives filed with their PCPs.

In home-health hospice, the patients that pass at home are DNR (another hot topic for another thread). They have comfort measures marked on their POLST in most instances. If not, that's one of the things the intake nurse does when interviewing the family for hospice services is have them fill out a POLST correctly. Marking the box "comfort measures only" and DNAR (do not attempt resuscitation) doesn't mean that nothing is done. On the contrary: suction, fluids are still given if requested, nebulizer TXs, O2, appropriate meds, wound drsg, etc... is supplied. Many times family and patients get very nervous when they see the box "no Abxs, use other measures to relieve symptoms" but Abxs can still be used when requested: certain situations like UTI, if already existing ABx order, etc... for comfort (as long as they are still taking meds).

I will manually write out things on the POLST the family is anxious about to assure them it can be given/done right. The tough one is the nutrition by tube. People aren't educated that most patients who are passing need to be dehydrated at the end of their journey (another topic for another time).

Many Health care staff like to have the POLST posted in the family's house. I put it somewhere discreet. Just so staff knows and is aware where it is and what it says along with any family members or friends who will be participating in the patient's treatment. Many times some nurses will post it on the fridge or somewhere obvious which IMO isn't conducive to a stress free passing.

I'm also one of those nurses who doesn't like to have a lot of signs everywhere. When a patient is passing usually that means there is 24/7 care. It's their home and doesn't need to be changed save for entry of the hospital bed (if requested) and medical equipment. I like to put the bed right smack dab in the middle of the main room. Of course if they prefer their bedroom that's fine, but it's only happened to me once. The bedroom was huge and had a view you couldn't imagine.

So, unlike standing orders in a facility: at home hospice standing orders are indicated by POLST and then the doc will write them out according to your comfort kit and situation. Usually these days docs will include all meds that come with the comfort kit. Anything extra is fairly easy to get...just speak up.