Comprehensive Approach to POLST and Advance Care Planning for a Spanish-Speaking Patient with Advanced Cardiopulmonary Disease
#1: Interpreter Services - Absolutely Required
Yes, you must order a professional medical interpreter for this visit. The European Society of Cardiology explicitly recommends that professional interpreters be used for advance care planning discussions with patients who speak a different language, to ensure precise communication about complex medical concepts, prognosis, and treatment preferences 1. Family members should not serve as interpreters, even if they are present, because they may have their own preferences that conflict with the patient's wishes 1. This is a legal and ethical obligation under Title VI of the Civil Rights Act, which mandates interpreter services for patients with limited English proficiency 2. Professional interpreters are superior to ad hoc interpreters (family, friends, or untrained staff) and reduce the risk of errors, confidentiality violations, and poor outcomes 2.
Key practice points for working with the interpreter:
- Seat the interpreter next to or slightly behind the patient 2
- Address the patient directly, not the interpreter 2
- Keep statements short and limit the discussion to three major points 2
- The interpreter serves as both a conduit and cultural liaison 2
#2: Three Critical Education Points
Education Point 1: Realistic Survival Expectations for CPR
The patient and daughter need to understand that CPR in patients with multiple comorbidities like Sylvia's has survival rates less than 5%, often less than 1%. 1 The American College of Chest Physicians specifically recommends educating patients about the extremely poor survival rates for CPR in patients with CAD, COPD, and recent critical illness requiring intubation 1. The daughter's concern about rib fractures is valid, but the more critical issue is that even if CPR is performed, Sylvia is extremely unlikely to survive to hospital discharge given her recent sepsis, prolonged intubation, heart failure, and advanced COPD 1.
Education Point 2: What "Doing Everything" Actually Means
"Doing everything" has different meanings in different clinical contexts, and the family needs to understand the distinction between current medical support and life-sustaining interventions. 1 The National Comprehensive Cancer Network suggests educating patients that aggressive interventions may prolong the dying process rather than restore meaningful quality of life 1. For Sylvia, "doing everything" could mean optimizing her COPD management, treating infections early, managing heart failure, and ensuring comfort—not necessarily subjecting her to repeated hospitalizations and invasive procedures that are unlikely to change her trajectory 1.
Education Point 3: POLST Creates Binding Medical Orders
The POLST form creates actionable medical orders that follow the patient everywhere and must be honored by emergency medical services, hospitals, and nursing facilities. 1 The European Respiratory Society emphasizes that these are not just wishes or preferences—they are physician orders that emergency responders and healthcare facilities are legally obligated to follow 1. This means if they select DNR and EMS is called, paramedics will not perform CPR. The family needs to understand this is different from a living will or advance directive 1.
#3: Recommended POLST Selections (Sections A & B)
Section A: Cardiopulmonary Resuscitation
I would recommend "Do Not Attempt Resuscitation (DNR/DNAR)" for Section A. The American Geriatrics Society recommends that patients with advanced cardiopulmonary disease and poor prognostic factors, such as multiple comorbidities and recent sepsis, be considered for DNR status 1. Given Sylvia's recent critical illness requiring 3 days of intubation, her baseline oxygen dependence (3 LPM), severe COPD with emphysema, CAD, heart failure, and current functional decline (SOB on minimal exertion), her survival from cardiac arrest would be less than 1% 1. The daughter's concern about rib fractures from compressions actually reflects an intuitive understanding that CPR would be traumatic and futile in this context 1.
Section B: Medical Interventions
I would recommend "Selective Treatment" or "Comfort-Focused Treatment" for Section B, leaning toward Comfort-Focused given her trajectory. The National Institute on Aging suggests that patients who prioritize quality over quantity of life may be more appropriate for Comfort-Focused Treatment, which focuses on symptom management and avoids hospitalizations and aggressive interventions 1. However, given the family's initial statement about "wanting to do everything," Selective Treatment may be the appropriate starting point, allowing for:
- Treatment of reversible conditions (e.g., antibiotics for pneumonia, diuretics for heart failure exacerbation)
- Transfer to hospital if needed for specific treatable conditions
- No intubation or ICU-level interventions
- Focus on maximizing function and comfort 1
Critical caveat: This recommendation assumes the patient herself, when directly asked through the interpreter, confirms she wants some medical interventions. The European Society of Cardiology emphasizes that we must distinguish between the daughter's preferences and the patient's actual wishes 1.
#4: Guidance for the Two-Month Follow-Up Visit
At this visit, Sylvia is clearly expressing a preference to avoid hospitalization and is spending most days in bed—this represents significant functional decline and likely signals transition to end-of-life. 3 The European Heart Journal guidelines on pulmonary hypertension note that recognition of poor prognosis may enable a "do not resuscitate" order and increase the chance of patients being in their preferred place of care at the end of life 3.
Specific Guidance to Offer:
Acknowledge her declining trajectory directly and honestly:
- "Sylvia, I can see that you are getting weaker and spending more time in bed. Your body is telling us that your heart and lungs are having more difficulty. It sounds like you don't want to go back to the hospital. Can you tell me more about what's most important to you now?" 3
Explore her goals and values systematically:
- What does a good day look like for her now? 4
- What symptoms bother her most (shortness of breath, fatigue, anxiety)? 3
- Where does she want to be cared for (home, with family)? 3
- What are her fears about dying? 3
Introduce palliative care and hospice services:
- The American Heart Association emphasizes that "palliative care should be integrated across stages of illness, starting early and intensifying in end-stage disease," with attention to "relief of suffering" as the primary goal 4
- Explain that hospice can provide intensive symptom management at home, with 24/7 support, medications delivered to the home, and support for the family 3
- Clarify that hospice does not mean "giving up"—it means shifting the focus to quality of life and comfort 3
Address practical concerns:
- Discuss what happens if she becomes more short of breath at home (oxygen adjustments, morphine for dyspnea, anxiolytics) 3
- Ensure the family understands not to call 911 unless that's what the patient wants, as EMS will follow the POLST orders 1
- Provide anticipatory guidance about the dying process so the family knows what to expect 3
#5: Should You Complete a New POLST Form?
Yes, you should absolutely complete a new POLST form at this visit. The patient's clinical status has changed significantly—she has declined functionally, is now bedbound most of the day, and has explicitly stated she does not want to return to the hospital 1. These changes in her condition and preferences necessitate updating her POLST to reflect her current wishes 1.
Rationale for New POLST:
The patient's goals have evolved: Two months ago, the family wanted "selective treatments" with possible hospital transfer. Now, Sylvia herself is expressing a preference to avoid hospitalization, which represents a fundamental shift in her care goals 1. The European Society of Cardiology emphasizes that POLST should be reassessed when there are significant changes in health status or patient preferences 1.
Her functional decline indicates disease progression: Spending most days in bed with worsening fatigue represents a significant change from her baseline two months ago (when she was at least ambulatory enough to attend office visits) 3. This decline suggests she is entering the terminal phase of her illness 3.
New POLST selections would likely be:
- Section A: Continue DNR (no change) 1
- Section B: Transition to "Comfort-Focused Treatment" given her stated preference to avoid hospitalization and her functional decline 1
- Section C: Continue "No artificial nutrition" (no change, as previously decided) 4
Documentation is critical: The American College of Cardiology emphasizes that all discussions and decisions must be recorded and communicated to all providers involved in the patient's care to prevent fragmented decision-making during crises 4. The new POLST should be shared with her home health agency, any specialists, and the local EMS system 1.
Use the professional interpreter for this discussion: This conversation about transitioning to comfort-focused care is even more nuanced than the initial POLST discussion and requires precise communication about her wishes, fears, and goals 1.