Approach to POLST Discussion in a Spanish-Speaking Patient with Advanced Cardiopulmonary Disease
1. Interpreter Services
Yes, you must order a professional interpreter for this visit. The patient speaks only Spanish, and advance care planning discussions require precise communication about complex medical concepts, prognosis, and treatment preferences 1.
Key reasons for interpreter use:
Effective communication is critical for advance care planning to ensure patient preferences are accurately understood and documented, as these discussions involve nuanced concepts about life-sustaining treatments that cannot be adequately conveyed through family interpretation 1.
The daughter should not serve as interpreter even though she is present, because family members often have their own preferences that may conflict with the patient's wishes, and research shows family members ask more questions than patients during code status discussions, potentially creating conflicts between family wishes and patient preferences 2.
Functional health illiteracy about life-sustaining treatments is significant - studies show 66% of individuals don't know mechanical ventilation is often needed after resuscitation, 37% think ventilated patients can talk, and 20% think ventilators are oxygen tanks 1. These misconceptions must be addressed through clear, direct communication in the patient's language.
The patient has decision-making capacity (she is not in acute distress and is stable), so her own preferences must be elicited directly, not filtered through family interpretation 1.
2. Three Essential Education Points
Education Point 1: Realistic Outcomes of CPR in Her Clinical Context
Educate about the extremely poor survival rates for CPR in patients with her multiple comorbidities - for patients with chronic illness like her CAD, COPD, and recent critical illness requiring intubation, survival rates after in-hospital cardiac arrest are less than 5%, and for those with advanced illness, survival rates are often less than 1% 1.
Chest compressions and intubation are inseparable interventions - if the heart stops (requiring CPR), she will be pulseless and apneic, meaning she cannot breathe on her own and will require immediate intubation with mechanical ventilation 1. The concern about rib fractures is valid (44% of CPR survivors have significant functional decline at discharge), but attempting CPR without intubation is not medically feasible 1.
Her recent 3-day intubation experience is relevant context - she has already experienced mechanical ventilation during her sepsis/pneumonia/heart failure exacerbation, so she can reflect on whether she would want to undergo that again in the setting of cardiac arrest with <5% survival 1.
Education Point 2: The Difference Between Current Medical Support and Life-Sustaining Interventions
Clarify that "doing everything" has different meanings in different clinical contexts - continuing her current treatments (oxygen, medications for CAD/HTN/COPD, antibiotics for infections, treatment of heart failure exacerbations) is very different from CPR and mechanical ventilation during a cardiac arrest 1.
Full treatment (Section A: "Attempt Resuscitation/CPR") means if her heart stops, healthcare workers will perform chest compressions, intubate her, use medications and potentially defibrillation, and transfer her to intensive care - all with <5% survival given her comorbidities 1.
Selective treatment options exist that allow aggressive medical treatment of reversible conditions (antibiotics, oxygen, medications) while avoiding CPR if the heart stops, which may better align with goals of maintaining quality of life 1.
Education Point 3: POLST as Binding Medical Orders Across All Settings
Explain that POLST creates actionable medical orders that follow her everywhere - unlike advance directives which are often imprecise, POLST translates her preferences into specific orders that emergency medical services, hospitals, and nursing facilities must honor 1.
The form is transferable across care settings (home, ambulance, emergency department, hospital, SNF) and provides explicit direction about what interventions she wants or doesn't want 1.
POLST preferences can be changed at any time as her condition or preferences evolve, and should be revisited periodically, especially after significant health events like her recent hospitalization 1.
3. Recommended POLST Selections
Section A (Cardiopulmonary Resuscitation): Recommend "Do Not Attempt Resuscitation (DNAR/DNR)"
Based on her clinical profile, I would recommend DNR status given her age, multiple serious comorbidities (CAD, COPD on home oxygen, recent critical illness requiring intubation), and the family's stated concern about chest compressions 1.
Clinical reasoning:
Survival probability is <5% for patients with her chronic illnesses (CAD, COPD requiring oxygen, recent sepsis/pneumonia/heart failure), and likely <1% given the severity of her recent decompensation requiring intubation 1.
Poor prognostic factors are present: multiple comorbidities, chronic illness, recent sepsis, and baseline functional limitation (SOB on minimal exertion) 1.
The family's concern about rib fractures suggests they may not fully understand that CPR without intubation is not possible - if she is pulseless and apneic (the indication for CPR), she will require both chest compressions AND mechanical ventilation 1.
Her recent intubation experience provides informed context - she knows what mechanical ventilation involves, and given her baseline dyspnea on minimal exertion and oxygen dependence, the likelihood of successful extubation after CPR is extremely low 1.
Section B (Medical Interventions): Recommend "Selective Treatment" or "Comfort-Focused Treatment"
I would recommend "Selective Treatment" as the starting point for discussion, which allows:
Full medical treatment of reversible conditions (antibiotics for pneumonia, treatment of COPD exacerbations, management of heart failure, oxygen therapy) 1.
Transfer to hospital if needed for treatable conditions while avoiding intensive care interventions like mechanical ventilation 1.
This approach aligns with "wanting to live" while acknowledging realistic limitations given her poor prognosis with CPR 1.
Alternative consideration - "Comfort-Focused Treatment":
If further discussion reveals she prioritizes quality over quantity of life, especially given her baseline fatigue and dyspnea on minimal exertion, comfort-focused care may be more appropriate 1.
This would focus on symptom management (oxygen for comfort, medications for dyspnea, pain control) while avoiding hospitalizations and aggressive interventions 1.
Critical caveat: The final decision must come from the patient herself after she understands the realistic outcomes - POLST should convert patient-centered treatment goals into actionable medical orders while the patient maintains capacity, which she currently does 1. The daughter's preferences should inform but not override the patient's own wishes once properly elicited through professional interpretation 1.