Artwork by Hilary Cole
by Robert A. Duke
Its title alone demands your attention, but this form may also impact your death one day: Physician Orders for Life-Sustaining Treatment (POLST)! The orders are your orders to an unknown physician(s) suddenly confronted with life or death treatment when you may be unconscious and dying.
Do you have a POLST? Well, you probably don’t, but you could have one with little effort and no cost. With its 2017 revisions, it’s the best POLST yet.
While officials intend the form for use by what they call “… patients with serious illnesses or frailty for whom their health care professionals would not be surprised if they died within a year,” it is available for anyone at any time, so I ask: “Why wait?” Those opposed to wider adoption of the POLST say it is unreasonable to ask younger persons to make decisions required by the POLST, but advance directives, recommended for those 18 years and older, ask the same questions but in more general terms. For example, POLST may ask point blank whether you want CPR, where an advance directive may ask what you think of CPR. In either case you either want it or don’t want it.
Because It’s Accessible
The POLST has many benefits, its greatest being accessibility. Bluntly, healthcare providers can find and use the POLST when it is most needed (which is why they created it), because other end-of-life documents (under various and confusing titles) are largely inaccessible when most needed. These include last estate will and testament, living will, advance directive, healthcare power of attorney, and do not resuscitate (DNR) order.
Consider End-of-Life Washington’s posting at endoflifewa.org regarding accessibility:
“The truth is that health care providers frequently ignore advance directives, and the law isn’t much help. No state forces a doctor or hospital to follow instructions in an advance directive. POLST, however, represents your wishes as clear medical orders. POLST improves your chances of getting what you want and avoiding what you do not want at the end of life. We recommend POLST to all our clients.”
What? Healthcare providers ignore advance directives? (See Whatcom Watch, March 2018, page 4, Whatcom: Chronic & Acute column.)
1. Electronic health records (EHR) are so poor that advance directives cannot be located, 2. Advance directives are so poorly organized as to make them unusable in an emergency, and
3. Medical information in advance directives is typically unclear, contradictory and incomplete. (See Glossary of Clinical Terms for ICU and ER Procedures at robertaduke.com blog for accurate directive vocabulary.)
The essential value of POLST is the ability to access the POLST form, which contains the medical orders that are to be enacted according to the patient’s end-of-life care preferences. Whether clinics use paper or EHR, the POLST is prominently and immediately accessible within the patient’s chart, due to efforts by those affected by operation of the healthcare industry. Similar support for advance directives has not yet been achieved.
Advance directive deficiencies can be corrected, but it is the responsibility of patients, caregivers, spouses, children and others who frequently lack the will and ability to properly execute an advance directive. Help is available from community organizations, such as Bellingham’s Whatcom Alliance for Health Advancement (WAHA), but the initiative lies with the public.
My late wife and I completed our first POLST in 2005, when she was age 59 and I was 67, and both healthy. We revised them in 2010 when she was diagnosed with terminal brain cancer. In 2011 I stood by while she discussed her POLST with doctors at her bedside in intensive care less than 24 hours before she died.
To me, these 2017 changes reflect the importance of the POLST in getting the best treatment for your needs and wishes any time you might be hospitalized. Importantly, POLST now explicitly recognizes the possible existence of an advance directive (be it somewhere in the system).
The one critical thing the POLST does not do is name a healthcare agent to speak for you at the end-of-life if you are unable to speak for yourself. For that, you must have an advance directive giving someone your power of attorney for healthcare to speak for you. Without an advance directive a court may make end-of-life decisions for you.
To be valid, your POLST must be signed by your doctor and scanned or otherwise entered into your provider’s electronic healthcare records and should be included with your advance directive and other health paper work.
Washington’s POLST History
Notice! Information about the POLST presented here is about only Washington State’s POLST. POLST forms vary from state to state.
The National POLST Paradigm (meaning example or model) at polst.org/about-the-national-polst-paradigm/history is probably the most authoritative source of its history, which follows:
“In 1991 leading medical ethicists in Oregon discovered that patient preferences for end-of-life care were not consistently honored. Recognizing that advance directives were inadequate for the patients with serious illness or frailty — who frequently require emergency medical care — a group of stakeholders developed a new tool for honoring patients’ wishes for end-of-life treatment, the POLST form. In September 2004 the National POLST Advisory Panel, later known as the National POLST Paradigm Task Force (NPPTF), convened to establish quality standards for POLST Paradigm Forms and Programs and to assist states in developing the POLST Paradigm. At that time only six states had POLST Paradigm Programs: New York, Oregon, Pennsylvania, Washington, West Virginia and Wisconsin.”
On February 17, 2017, fourteen health care organizations, including the National POLST Paradigm Office, joined together in sending a letter to Tom Price, Secretary of the U.S. Department of Health and Human Services, and David Shulkin, Secretary of the U.S. Department of Veterans Affairs. According to Amy Vandenbroucke, Executive Director of the National POLST Paradigm,
“The purpose of the letter is to present a range of policies advancing palliative and end-of-life care that likely improves care for those who are seriously ill and near the end of life.’ This document supports the POLST Paradigm by encouraging its use within appropriate populations and emphasizing the importance of having POLST Forms available through a single-click in an electronic medical record.”
Wikipedia states that POLSTs currently exist at some level in 42 states and meet the national POLST standard in 18 states.
Robert A. Duke is author of “Waking Up Dying: Caregiving When There Is No Tomorrow,” he lives in Bellingham. His email: firstname.lastname@example.org