There are several types of advance planning documents that individuals may use to declare their preferences for health care and mental health decisions in the event that they become incapacitated. An advance directive is a document that expresses an individual's preferences regarding the withholding or withdrawal of life-sustaining treatment if he or she is in a terminal condition or permanent unconscious state. A mental health advance directive is a document that either provides instructions or declares an individual's preferences regarding his or her mental health treatment in the event of incapacitation. A durable power of attorney for health care is a document that appoints an agent to provide informed consent for health care decisions on behalf of another individual.
The Portable Orders for Life Sustaining Treatment (POLST) form is another type of document implemented by the Department of Health (DOH) that is designed for seriously ill individuals and those in poor health. The POLST is a standardized form that is signed by an individual's physician, physician assistant, or advanced registered nurse practitioner to instruct emergency medical personnel or staff in residential care settings on the type of care that an individual wishes to have in end-of-life situations. The POLST form allows individuals, through their health care provider, to indicate whether they would like to receive cardiopulmonary resuscitation (CPR), if necessary, as well as the level of medical intervention they would like to receive.
In 2006 the DOH was directed to establish and maintain a statewide registry of health care declarations submitted by Washington residents on a secure website, which included advance directives, durable powers of attorney for health care, mental health advance directives, and POLST forms. Funding for the registry was eliminated in 2011.
Completion and Review of Portable Orders for Life Sustaining Treatment Forms.
Electronic signatures may be utilized in place of handwritten signatures on Portable Orders for Life Sustaining Treatment (POLST) forms. An individual's verbal confirmation of the POLST form satisfies any requirement for their signature if requiring the individual to sign the form in person or electronically would require significant difficulty or expense and a licensed health care provider witnesses the verbal confirmation and signs the form attesting that the provider witnessed the confirmation. The witnessing health care provider may not be the same provider who signs the order and must verify the identity of the individual who is providing the verbal confirmation.
Providers who are treating an individual who has completed a POLST form may review the individual's form with them on an annual or more frequent basis to ensure that it reflects the patient's current health status and treatment preferences.
Statewide Portable Orders for Life Sustaining Treatment Registry.
Portable Orders for Life Sustaining Treatment forms are removed from the types of health care declarations that an individual may submit to the existing, unfunded registry. The Department of Health (DOH) must establish and maintain a new statewide registry containing POLST forms submitted by health care providers and Washington residents. The POLST registry must be designed to allow for future expansion to support the addition of other health care declarations such as advance directives, durable powers of attorney for health care, and mental health advance directives.
The registry must:
The provider that signed a completed POLST form or their agents or employees must submit the form to the DOH or registry consistent with the standards adopted by the DOH on the individual's behalf, unless the individual has opted out of submitting the form to the registry. The POLST form itself must include an option for the individual to opt out of their provider submitting their form to the registry. Additionally, an individual or the individual's personal representative may submit the individual's POLST form in digital format to the DOH for inclusion in the registry. The DOH must collaborate with health care providers and individuals to establish best practices for health care providers that sign POLST forms to discuss with individuals if the form should be submitted to the registry and how the form will be submitted.
The DOH must review the POLST forms it receives to determine if they comply with all requirements, and must digitally reproduce and store the submitted POLST forms in the registry. The DOH must establish standards for providers and individuals to submit POLST forms directly to the registry. The DOH must also prescribe procedures for an individual to revoke POLST forms contained in the registry, and for removal or archival of an individual's POLST form on request of the individual or upon confirmation that the individual who completed the form has died.
The POLST registry must be designed to comply with state and federal requirements related to patient confidentiality. The registry is exempt from public copying and inspection for purposes of the Public Records Act, however, the DOH may allow qualified researchers access to deidentified registry data.
Failure to submit a POLST form to the DOH does not affect the validity of the form. Failure to notify the DOH of a valid revocation of a POLST form does not affect the validity of the revocation. The entry of a POLST form in the registry does not affect the validity of the POLST form, take the place of any existing requirements necessary to make the form legal, or create a presumption regarding the validity of the form.
The DOH may accept donations, grants, gifts, or other forms of voluntary contributions to support activities related to the creation and maintenance of the registry and public education campaigns. All receipts from donations made, and other contributions and appropriations for creating and maintaining the registry and statewide public education campaigns must be deposited into the General Fund. These moneys may be spent only after appropriation.
Immunity from Legal Liability and Professional Conduct Sanctions.
Except in instances where there is greater liability protection, any provider who participates in good faith in the provision of medical care or the withholding or withdrawal of treatment from a person in accordance with the person's POLST form is immune from legal liability, including civil, criminal, or professional conduct sanctions, unless otherwise negligent. The establishment of the registry does not create any new or distinct obligation for a provider to determine whether a person has completed a POLST form.
Except for acts of gross negligence, willful misconduct, or intentional wrongdoing, the DOH is not subject to civil liability for any claims or demands arising out of the administration or operation of the registry. A provider is not subject to civil or criminal liability or sanctions for unprofessional conduct when, in good faith and without negligence, the provider provides, does not provide, withdraws, or withholds treatment:
Report on Alternative Evidence.
The DOH must research options for types of alternative evidence that may be utilized to indicate that a person has completed a POLST form and does not wish to have resuscitative efforts, for example, medical jewelry, a physical card, or an electronic application-based form. The DOH must submit a report to the Legislature by June 30, 2026, with recommendations regarding whether alternative evidence should be implemented and in what form, guidelines and protocols for emergency medical personnel to recognize alternative evidence, and standards for production and endorsement of alternative evidence.
The substitute bill requires, rather than authorizes, providers to submit completed Portable Orders for Life Sustaining Treatment (POLST) forms to the registry, unless the individual who completed the form has opted out. The provision related to ensuring the registry and website comply with state and federal patient confidentiality requirements is modified to add a requirement that the Department of Health store and protect data in the registry in accordance with the state requirements to protect health care information. An exception is added to the provisions establishing liability protection for providers acting in accordance with a POLST form or the registry for instances in which the provider is afforded greater liability protection elsewhere in law. Changes are made to use the current law term "advanced registered nurse practitioner" rather than "advance practice registered nurse," which will not be the official name of the profession until 2027.
(In support) Portable Orders for Life Sustaining Treatment (POLST) forms help people have their end-of-life decisions honored. POLST forms are meant for people living with serious illness who, in concert with their provider, fill out the POLST form that translates their wishes into an actual medical order. The system works very well to protect vulnerable patients who may still be active in their communities and are not homebound. In one example, an elderly patient was hospitalized for a stroke despite verbalizing that she did not want to go to the hospital. This patient was clear that the next time she did not want to be taken to the hospital and completed a POLST form, which will allow responders to honor her wishes. Another elderly patient was under the care of a palliative team. In this case, intervention would be potentially more harmful than beneficial. Despite having a POLST form, he went into cardiac arrest at a senior center and had full medical intervention performed, including cardiopulmonary resuscitation (CPR), intubation, and hospitalization, leading to the family having to decide to discontinue life support. If emergency responders had a way to know that he had a POLST form, they could have provided comfort measures instead and honored his wishes.
The bill recreates a registry that was cut during the recession. The registry will streamline the updating process and make it easier to revoke and change forms if desired. Other positive aspects of this bill are allowing electronic signing of forms and verbal confirmations, providing immunity, and incorporating secure data measures. A prior bill on this topic generated a lot of positive discussion about end of life decisions. Since then, discussions with agency staff, providers, and other interested stakeholders have refined the policy. This bill takes some concepts from the prior bill, like incorporating medical jewelry or other alternative evidence to let paramedics know someone does not wish to be resuscitated. Alternative evidence can be helpful in instances in which cell coverage limits access to data. This bill instead has the Department of Health look at options for this.
(Opposed) None.
Representative Dave Paul, prime sponsor; Sharmon Figenshaw, Washington POLST Task Force; and Hilary Walker.