A Better Way to Honor Patient Preferences and Code Status

POSTED: March 21st, 2025
POSTED IN: EM Pulse Q1 2025,

Written by: Chuck Crecelius, MD Medical Director, Delmar Gardens West & Delmar, Gardens on the Green; Associate Professor of Geriatrics, Washington University School of Medicine

TPOPP/POLST is a national paradigm designed to ensure a person’s wishes regarding end-of-life care are carried out. It stands for Transportable Physician Orders for Patient Preferences / Physician Orders for Life-Sustaining Treatments. This form ensures that code status orders are honored across all sites of service (e.g., home, nursing home, assisted living, dialysis) using a single form. It is a medical order that must be followed at all times and in all places. TPOPP/POLST complements and reflects advance directives, which are not medical orders, and is superior to the current Out-of-Hospital DNR (OHDNR) form used in Missouri.

The use of TPOPP/POLST in Missouri was previously limited due to the lack of “ambulance indemnity,” meaning EMS personnel could not be protected from legal actions when following the form in good faith. A new law, which applies to all persons, including pediatric code status, goes into effect on December 30, 2024, and provides ambulance indemnity. Previously, this protection was only afforded to the Missouri Out-of-Hospital DNR (OHDNR) form, which is valid only in Missouri. The OHDNR form solely addresses CPR and applies only outside the hospital; it does not account for limited code status and becomes invalid once the patient is admitted to a hospital.

Unlike the OHDNR form, TPOPP/POLST allows for time-limited trials (e.g., intubation or artificial feeding for a week to determine effectiveness). Additionally, the OHDNR form can only be completed by a competent person, a Durable Power of Attorney for Health Care (DPHCA), or a guardian (not proxies), whereas TPOPP/POLST offers broader eligibility. Upon hospital discharge, if an OHDNR form is not completed, the patient defaults to full code status until paperwork is finalized, even if they are on hospice. However, with a TPOPP/POLST form, a medical order remains in effect 24/7, regardless of the site of service. For instance, if a TPOPP/POLST form is completed, there is no need to fill out an OHDNR form or obtain a physician’s signature upon admission or discharge—the same TPOPP/POLST form can be verified to reflect the patient’s wishes and used accordingly.

Because TPOPP/POLST is active 24/7, best practices suggest reviewing care preferences when:

Transferring from one care setting to another
There is a substantial change in condition
Treatment preferences change
The care provider changes

Best practices also support an annual review with the patient’s primary care provider, such as during the Medicare Annual Wellness Exam. Preferences and effective treatments evolve over time. In emergency situations (e.g., an ER visit where the patient is unresponsive and in acute distress), care should be provided according to the TPOPP/POLST form as the most reliable treatment plan until a comprehensive assessment is performed and the form is updated.

The patient or their legal representative should safeguard and retain the original form. The signing provider must ensure that the form is placed in the medical record and that it accompanies the patient if they are transferred to another provider. Copies are legal, and entities requiring the TPOPP/POLST form should retrieve or make copies of the dated form and place them in the appropriate section of the patient’s chart. Proprietary efforts are underway to establish a national repository for such forms, which could be accessed with the patient’s permission to ensure their expressed wishes are honored regardless of where they seek medical attention.

A patient with capacity can request other treatments or revoke their TPOPP/POLST at any time. The front page should have a line drawn through it with “VOID” written in large letters, signed and dated. A legally recognized decision-maker can request modifications in collaboration with the physician, based on the patient’s known wishes, advance directives, and best interests. If requested changes appear to contradict the patient’s known wishes, ethics or legal teams should be consulted for further review.

Missouri law mandates that the form must be signed by a physician to be legally valid. Nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) cannot sign the form but may participate in discussions and guidance. Social services and nursing staff may also engage in discussions, but the form must ultimately be reviewed and signed by a physician. Due to the physician signature requirement, state reciprocity is limited.

The following states currently have reciprocity:

Alaska
Arkansas
Georgia
Indiana
New Mexico
Kansas

Insurance providers will reimburse physicians and other qualified health professionals, such as nurse practitioners, for advance care planning (ACP) when sufficient time is allocated for completion (minimum 16 minutes) and when medical necessity is established. Physicians are not required to complete forms like TPOPP/POLST to bill for ACP, but these forms should be discussed. If ACP is billed during an Annual Wellness Exam, there is no copay, making this an ideal time to initiate or review a TPOPP/POLST form, provided that medical necessity exists.

To obtain more information and access the TPOPP/POLST form, please visit the following link: https://www.practicalbioethics.org/programs/transportable-physician-orders-for-patient-preferences-tpopp-polst/

The actual regulation can be found starting on page 55 at: https://www.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c30-40a.pdf

Summary of Key Points:

TPOPP/POLST can be used for patients with limited life expectancy and is a medical order in effect wherever the patient goes.
TPOPP/POLST is superior to the Missouri OHDNR form for most frail elderly individuals because it allows for limited code status and time-limited trials.
TPOPP/POLST must be signed by a physician to ensure it accurately represents the patient’s wishes. Other providers and patient representatives may participate in discussions but cannot sign the form.