Our work with POLST perhaps best exemplifies the value of a coalition. Successful establishment of POLST in a state requires working collaboratively with a wide range of stakeholders on both a statewide and local level. We've been so successful that sometimes people equate the Coalition with POLST in our state.

POLST is a physician order that gives patients more control over their EOL care. Produced on a distinctive bright pink form and signed by both the physician and patient, POLST specifies the types of medical treatment that a patient wishes to receive toward the EOL. It encourages communication between providers and patients, enables patients to make more informed decisions, and clearly communicates these decisions to providers. As a result, POLST can prevent unwanted or medically ineffective treatment,
reduce patient and family suffering, and help ensure that patients' wishes are honored.

For years, the Coalition had heard about POLST. Several times, CCCC leaders and members discussed whether to bring it to California. Each time the decision was not to do so. We knew that establishing proper usage of POLST would take more than just putting POLST into law or encouraging use of the form. We knew that it would take education—lots of education. That, in turn, would require committed resources sustained over time.

In 2007, three local communities in California expressed interest in using POLST in their local area. Because the Coalition believed that it was important to have statewide standards and consistency for POLST to work in our state, the Coalition made a commitment to establish POLST in California.

The Coalition approached the California Health Care Foundation (CHCF) with a grant proposal to establish POLST in our state. CHCF approved the grant, which provided start-up funds for the Coalition to lead statewide efforts, as well as funds to support efforts in eight communities.

The National Hospice and Palliative Care Organization (NHPCO) had announced a one-day workshop on POLST to be held three months after CHCF committed to funding POLST activity. So the Coalition and CHCF quickly developed a call for proposals for local community leaders and organizations that wanted to be one of the eight initial POLST coalitions. In November 2007, a group of about 20 people from California attended the NHPCO POLST workshop. This provided a strong informational foundation for our POLST work, as well as created a common identity among our initial POLST leaders.

Early on in our efforts to spread word about POLST in our state, we learned:

■ POLST is only as good as the conversation on which it is based. The role of POLST is to document the conversation.

■ POLST compliments an AD. ADs fill another, just as critical, need.

■ POLST helps systematize solicitation, documentation, and transfer of patient wishes. By doing so, it highlights weaknesses in our health system. This may be disconcerting to some and appear that POLST is causing problems. In reality, POLST provides us a service by highlighting where we need to focus our efforts to improve our system.

The Coalition established a Task Force to oversee all statewide aspects of POLST, including public policy, content of the form, communication and messaging, standardized education, quality improvement, and evaluation of our efforts. The California Task Force is comprised of the following:

1. Twenty organizations that represent providers impacted by POLST, such as the medical association, hospital association, nursing home associations, and organizations representing emergency responders;
Eight state agencies that oversee those providers, including the Medical Board, Department of Public Health, and Emergency Services Authority;

2. Five organizations representing the consumer perspective, such as AARP and California Advocates for Nursing Home Reform; and

3. Three EOL coalitions.

We continue to add Task Force members as additional organizations and agencies are identified.

One of the strengths of POLST is that it applies across care settings. At the same time, one of the challenges of POLST is that it applies across care settings. The way that health care providers in one part of the health care continuum view and react to POLST can be very different from providers in another part. For example, emergency responders have limited training, have to act in a split second, and are trained to follow protocols. Physicians, on the other hand, have extensive education and exercise a lot of clinical judgment. This can impact how different Task Force members, representing different parts of the health care continuum, view various issues related to POLST. Thus, it's critical to have the perspective of all interested parties represented on the Task Force.

Because California is such a large state, we believed that it would be helpful to establish POLST in state law. We wanted to make it clear that POLST was “legal” and to provide an incentive to providers to honor POLST forms by providing immunity for doing so. We decided to take the legislative route.

To minimize potential opposition, we amended California's existing do not resuscitate (DNR) statute, rather than creating a brand new statute. We did our work behind the scenes, by addressing concerns raised by various constituencies and educating legislative staff on the bill. As a result, California Assembly Bill (AB) 3000 went through both houses of our legislature with unanimous support. AB 3000 was signed into law in 2008 and went into effect on January 1, 2009.

To facilitate uniform adoption of POLST in our state, we developed standardized messaging to explain what POLST is, who would benefit from POLST, how it operates, and how it relates to ADs. We use the message platform throughout all our materials.

In addition, we developed a standardized 2-day, train-the-trainer curriculum on POLST. The curriculum emphasizes the importance of the POLST conversation and involves extensive role play and skill building in having the conversation. As POLST can be used with children, the Coalition collaborated with the Children's Hospice and Palliative Care Coalition to create a 1-day curriculum on POLST in the pediatric population. Providing education on POLST, particularly the POLST conversation, is important for maintaining quality POLST form completion. To further emphasize the importance of the POLST conversation, we developed a video on POLST conversations. The video is comprised of eight vignettes between real physicians and actor patients that highlight different aspects of the POLST conversation. None of the conversations in the vignettes are perfect. Rather, the vignettes provide rich learning opportunities for both what works and what doesn't work in the POLST conversation.

The Coalition also created numerous materials to support POLST implementation, including a brochure on POLST for providers; a brochure written at sixthto eighth-grade reading level for consumers; model policies and procedures on POLST for hospitals, nursing homes, and hospices; a quick reference guide on POLST in nursing homes; and frequently asked questions for consumers.

In our early days, the question arose whether we should pilot a single form in the state or, in attempt to identify the best version, pilot multiple versions in different communities. The national POLST leadership wisely urged us to have a single version for the entire state even during our pilot phase. Once multiple versions are introduced, people might become wedded to their version.

Next, we needed to decide on the content of the form. To keep our efforts focused on implementation, we decided to begin with the Oregon form, which had benefited from years of collective wisdom about what works and doesn't work. This eliminated our need to have extensive discussion about every detail on the form. We chose not to include a section on antibiotics, however, because research showed that this section had little impact on the care patients received.

We followed the advice of national POLST leaders, so 2 years into implementation we solicited suggested changes to the form. The thinking is that updating the form periodically based on actual usage in the field serves as a mechanism to maintain POLST quality.

In response to our call for suggested changes, we received more than 300 comments. To process these suggestions, the POLST Task Force created a committee that developed a process for sorting through, evaluating, and deciding on which suggestions to adopt. We found that many of the suggested changes actually reflected a breakdown in education rather than a weakness in the form. As a result, the committee set the standard that any suggested change would need to provide a substantial benefit in order to be adopted.

The committee reviewed the suggestions and developed a subset that they moved forward to the full POLST Task Force for input. The committee then met again to consider the feedback from Task Force members and developed a recommended revised form. The revised form went to the full Task Force for approval. Given our state's diverse population, the California POLST form has been translated into Armenian, Chinese, Farsi, Hmong, Korean, Pashto, Russian, Spanish, Tagalog, Vietnamese, and Braille. The translated form helps facilitate communication between providers and patients. Since English is the language of emergency responders, the signed form must be in English.

The Importance of Local Leadership

One of the hallmarks of California's POLST work is the recognition that successful establishment of POLST requires two strategies—one for impacting care on a statewide basis and one for impacting care at the bedside. Extensive statewide efforts don't guarantee that anything will change in the way care is actually provided. To make that impact, it takes local leadership.

In California, we used local coalitions to make that happen. We're now up to 27 local POLST coalitions. These coalitions, headed up by local champions for POLST, convene other leaders from across the continuum of care, pilot interventions, conduct education with groups of people and one on one, and assist in collecting data regarding POLST usage in their community. They are led by a wide variety of organizations, including local medical societies, hospitals, medical groups, educational and bioethics consortia, local coalitions already working on EOL issues, and others. As POLST is a physician order, local coalitions are expected to work with a physician who will champion POLST in the local community.

To keep the local coalitions connected to the statewide work as well as each other, we host monthly conference calls and annual in-person gatherings. The monthly conference calls are with the POLST physician champions and provide a forum for discussing clinical issues related to POLST, making sure that our efforts are always grounded in good clinical practices. POLST trainers—those who've attended our standardized train-the-trainer seminar—are supported on an ongoing basis through quarterly conference calls and webinars.

Effective implementation of POLST requires collaboration. California's success with POLST is a direct reflection of the extensive collaboration that has occurred on both a statewide and local level.

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