.”
The measure described is Physician Orders for Life-Sustaining Treatment
(POLST), sometimes also called Medical Orders for Life-Sustaining
Treatment (MOLST). According to the
,
POLST originated in 1991, and 14 states had adopted it by 2004, when
the National POLST Paradigm Initiative Task Force formed to expand the
practice.
.
A POLST is a medical order, signed by a physician, instructing a health
care provider about what types of life-sustaining treatment to provide
or withhold. The instruction is supposed to be based on the wishes of
the individual or their authorized surrogate health care decision
maker. The
, but not all states have adopted that requirement.
A primary concern about POLST is whether an individual’s POLST form
actually reflects their wishes, and whether the individual’s wishes are
based on informed consent. Other forms of advanced directives in which
people designate their health care wishes are not signed by physicians,
so they need to be translated into medical orders to direct health care
provider behavior, but POLST is a medical order that is effective
immediately. If you or someone else calls 911 in an emergency, the
emergency medical technicians (EMTs) know to look for a POLST form and
to do what it says. If the POLST form says “do not resuscitate”, then
the EMT’s are supposed to comply.
The Stateline article briefly but accurately reflects the disability community’s concerns as follows:
The reporter, Michael Ollove, also interviewed Cathy Ludlum from Second Thoughts Connecticut, and noted that:
I don’t know about you, but successful lobbying against a mainstream
bill by a disability rights group is not something I read about every
day. Second Thoughts CT developed an effective flyer, researched with
citations, to talk about the concerns they had with the bill. Among
other things, the flyer said:
Connecticut’s research was very helpful to me and led me to some additional resources.
,
which received 78 comments, including several by Stephen Drake, who
went toe-to-toe with other commenters, and myself. As Stephen noted,
“If the patient or surrogate signature isn’t required, this document is
less about safeguarding the rights and preferences of the patient than
it is relieving some perceived burden of uncertainty on medical
providers.”
My comment passed on the information that I got from CT, and connected the dots between POLST concerns and futility policies:
That last sentence sums it up for now. –
Joe
Takach talks to his friend Lillian Landry as she spends her last days
in the hospice wing of an Oakland Park, Fla. hospital. Many states have
adopted a new end-of-life document designed to ensure that a patient’s
wishes are respected as death approaches. (AP)
The emergency call came in at 10:47 on a Saturday night: “Woman in Overland Park with difficulty breathing.
Code one closest.”
Angela Fera, a paramedic in Johnson County, Kan., and her partner
raced to the house, sirens blaring. When they arrived, six minutes after
the first dispatch, a man told them that his 62-year old wife had
terminal cancer and was unconscious. The paramedics found her sitting
upright in bed, ghostly pale with a weak pulse and shallow breathing.
Death seemed imminent.
The woman was under hospice care, and had signed a “Do Not
Resuscitate (DNR)” order. She had made her wishes clear: She did not
want to be taken to the hospital if a life-threatening medical emergency
arose.
But the woman was not in cardiac arrest, the situation specified in
the DNR order. Protocol required that Fera try to save her life,
probably by inserting a plastic tube into her trachea to restore
breathing and transporting her to a hospital, where she’d be put on a
ventilator. Fera guessed that was precisely what the woman did not want.
But the husband felt that his wife’s children—his stepchildren—should
be the ones to decide whether to withhold treatment.
“We were completely fighting all our instincts to jump in and save
her, but on the other hand we really wanted to do what was right,” Fera
recalled.
New End-Of-Life Document
A new end-of-life document, more explicit and binding than a DNR and
advanced directives, is designed to clarify patients’ wishes—and spare
caregivers such as Fera from facing such wrenching choices.
A “physician order for life-sustaining treatment” (
POLST)
is a medical order, signed by a doctor or other authorized medical
provider. The product of a conversation between patient and provider, a
POLST specifies a patient’s goals and desires as death closes in. Unlike
a traditional DNR, it covers such medical interventions as
resuscitation, hospitalization, use of antibiotics, hydration,
intubation and mechanical breathing ventilation.
Without much opposition or attention, many states have adopted
POLSTs. This year, Indiana and Nevada approved legislation to allow
their use, leaving only seven states and the District of Columbia
without POLSTs in at least some stage of development.
They tend to come in garish colors—neon pink, orange, and green, for
example—so they stand out among other documents in a home. People are
encouraged to put them on their refrigerators, and paramedics are
trained to look for them there. In Oregon, where POLSTs originated in
the early 1990s, they are recorded in an electronic registry so first
responders can access them online. Other states are moving in the same
direction.
Research suggests POLSTs are effective in matching treatments to
patients’ wishes. According to one study, patient preferences noted on
POLST forms matched the actual treatment—or non-treatment—in more than
nine out of 10 cases.
Vague or Irrelevant
Dr. Susan Tolle, one of the creators of POLST and director of the
Center for Ethics in Health Care
at the Oregon Health and Science University, said DNRs and other
end-of-life documents tend to be vague or irrelevant to many medical
situations. In many cases, they are signed by somebody whose authority
may be in question during a medical crisis.
“We needed a portable system of actionable medical orders that would
follow the patient and be consistently respected across settings of
care, whether that was in a long-term nursing care facility, home,
hospice, the ambulance or an acute care hospital,” Tolle said.
POLSTs are often confused with advanced directives, but they differ
in significant ways. An advanced directive is often completed by a
healthy person, and is purely hypothetical. It lacks the medical
authority of a physician’s signature.
By contrast, a POLST is completed by a medical provider in
consultation with the patient. POLSTs are geared toward severely ill
patients who are expected to die within a year. According to Tolle, the
most common triggers for completing a POLST are when someone begins
hospice care, is admitted to a skilled nursing facility or is discharged
from the hospital where they had a DNR order.
Some Are Wary
All states require a medical provider to sign a POLST. In most, the
signer must be a physician, though some states allow other medical
personnel, such as nurse practitioners, to sign it. Most states also
require the signature of the patient or a designated surrogate but some,
such as Oregon and New York, do not.
Some disability rights groups have focused on the issue of patient
signatures. Without one, according to Diane Coleman, president of the
disability rights group
Not Dead Yet,
“How do we know the POLST medical order actually reflects the desires
of the individual?” Coleman worries that depending on how POLSTs are
presented, they can make life-sustaining treatments—such as the use of
feeding tubes—seem unbearable, even though many disabled people are able
to live full lives because of them.
Disabled rights groups lobbied successfully against POLST in Connecticut this year.
In Texas, Wisconsin and Florida, opposition to POLSTs has come from
Catholic groups. Edward Furton of the National Catholic Bioethics Center
worries that in cases where POLSTs do not cover the exact circumstances
of the moment, denying care may be akin to euthanasia. “When you look
at the POLST documents, they don’t take into account the circumstances
that the person is in at that particular time and place,” Furton said.
Nonetheless, there is no monolithic Catholic position on POLST.
POLSTs have received strong Catholic support in some states, including
California and Louisiana.
“This is not about ideology or religious views,” said John Carney,
president of the Center of Practical Bioethics in Kansas City, which has
worked to bring POLST to Missouri and Kansas. “This is about dignity
and making decisions about what I want about my own life.”
Fera’s Choice
At the scene of the emergency in Overland Park a year ago, Fera the
paramedic had to act fast: She asked the husband of the unconscious
woman to summon his stepchildren and a nurse from the hospice service.
Then she directed the fire crew to use a bag valve mask to help the
woman breathe for a short time.
When the woman’s children and the nurse arrived, they quickly
confirmed that the stricken woman had repeatedly said she didn’t want to
be revived in such a situation. With that assurance, plus approval via
radio from an emergency room doctor, Fera and her partner left the woman
at home in the care of the hospice nurse. They drove off, certain that
the woman’s end was near, and fairly sure that they had acted according
to her wishes.
Fera is grateful that she is less likely to face similar situations
in the future. In the year since responding to the call in Overland
Park, Johnson County has adopted POLSTs. “To say we like it,” she said,
“is an understatement.”
New End-of-Life Measure Quietly Sweeps the Nation
