Who Needs POLST?

           POLST (Physician Orders for Life Sustaining Treatment) is meant for people who have a life expectancy of less than two years. Primarily, POLST is used for the elderly; those not necessarily who are actively dying but have a number of medical problems with declining health. 

 Some examples 

Think about the 90 year old living in a nursing home that has had a couple of strokes, lung disease from years of smoking, and perhaps had a heart attack in the past. This person may no longer be able to get up and walk, do most of his basic care on his own. Adding to the medical problems, may now be some dementia. The dementia may cause this person to forget to eat and drink leading to a common bladder infection that can easily spread systemically. Another common scenario is this same person, who is no longer able to be physically active, not breathing deeply, then gets pneumonia. 

Another example would be someone who has been diagnosed twenty years with diabetes. Often diabetes goes uncontrolled; early on in the diagnosis, a person may say, “Well, I take the pill the doctor gives me”.  Yet, that person knows little about diabetes, what his HbA1C levels are (hemoglobin A1C measures the extra glucose in the blood). Ideally, that level should be 5 percent, that of a non-diabetic person. However, typically it is much higher, placing this person at risk for heart attacks, strokes, blindness, kidney failure and dialysis, as well as amputations. Many times this person is not physically active nor is eating a diet rich in fiber and low in fat. During the course of years, this person may experience enough of the complications that will land him in a nursing home. Now, this person with one leg amputated, having had a heart attack, stroke, and on kidney dialysis with loss of vision has a very poor quality of life. 

How would they benefit from POLST?

          By ensuring that those with complicated medical problems, limited mobility, and increased aging, have their end of life decisions addressed, those of us in healthcare can honor those decisions. 

            At some point, we all die. While someone involved in a trauma can recover, the likelihood of someone like we discussed above recovering from yet another stroke or heart attack is very slim. As the body ages, each vital organ loses some function, the more the disease processes on board, the more function is lost. Then, when the body is additionally stressed, that person really cannot recover, even to bring that person back to his lower level of functioning. 

            Through discussions with the patient and family, with input from whomever the patient and family think would help, such as the pastor or other spiritual advisor and healthcare provider, decisions can be made. These end of life decisions are then put in writing, signed by the physician, patient, and family. This way, everyone knows ahead of time what level of treatment healthcare providers will give. 

POLST - What About a Good Death?

                                          

           POLST (Physician Orders for Life Sustaining Treatment) has met with a great deal of success in honoring patients’ and their families’ end of life decisions. Unlike living wills and advance directives that consistently demonstrate in each and every research study that they are ineffective in honoring end of life wishes, POLST does just the opposite. 

Several research studies done using POLST

          Since Oregon was the state that first initiated the use of POLST, most of the first studies originated from there. A variety of research studies have been done using POLST with very impressive results. Over 95% of the time, patient and family end of life decisions are honored using POLST. Remember to compare this with studies done on the use of living wills that show virtually no compliance in honoring patient and family end of life decisions. 

Why does it matter if end of life decisions are honored?

            Studies have shown that most elderly people want to die where they live. This really makes sense when you think about it. They want to die where they are already comfortable, giving them a sense of security as they make the last journey of life. Elderly people do not want to be transferred to a hospital where they are poked and prodded with all sorts of invasive tests and tubes coming out of every orifice. They want to be comfortable with loved ones around them. There is such a thing as a ‘good death’ and we can provide that to elderly patients.

What is a good death?

   

            We are all going to die; this is the last stage of life, here on earth. When most of us think about death; that is, if we allow ourselves to entertain that we are not immortal and we will someday reach this stage of life, we want to be comfortable. 

Being comfortable is the mainstay of a good death. This might mean pain control, oxygen, surrounded by those you love. Most of us, and especially the elderly, do not think of dying surrounded by a bunch of machines making beeping noises, while healthcare staff continually take blood, or stick tubes in places that you would never imagine a tube would go. 

While we in healthcare can do much to prolong an elderly person’s life, we cannot necessarily give them back a quality of life. 

            Book from 1997 that began the discussion on a good death.

What the Heck is POLST?

 

We have discussed what is wrong with the way that we handle end of life issues. We know that most elderly people do not have living wills. We know that the 20 percent of the elderly that do have living wills do not have them honored for various reasons. Studies show that the elderly want to die where they live, not in the hospital. We know that every study done regarding the use of living wills all show that they do not make any difference in honoring what an elderly person wants at the end of life. So, what does work?

A Few States Have Adopted POLST 

            Knowing that what we have been doing for the last thirty years regarding trying to respect the elderly and their end of life decisions has not been working, a few states have adopted a plan that does work. 

            This plan is known as POLST (Physician Orders for Life Sustaining Treatment).  POLST is a simple one page, brightly colored form that is meant for people who have a life expectancy of one to two years. This form clearly states what treatments an elderly person does or does not want. While one might say this was the purpose of the living will, it fell short in many ways. 

Why does POLST Work?

            The one big difference is with POLST, the plan is signed by a physician, nurse practitioner, or physician assistant. This gives validity and legality to the form in a way that was not able to be done with the use of living wills.  In an age of litigation, the POLST form is signed by the physician, the patient and/or family member. 

            Since the first use of POLST, over twenty years ago, there has been no litigation regarding the use of POLST. Most likely it is because it is signed by a physician as well as the patient and/or family. Additionally, the form is to be kept with the patient at all times. Remember last week when we spoke about the use of living wills and how most patients and families do not remember where they are or what they say. Since the POLST form must be kept with the patient at all times, patients and families are very well aware of what it says. Those living at home are encouraged to have it laminated and placed on their refrigerator. Emergency medical technicians know to look for a POLST order there in the kitchen when coming to someone’s home. 

            We’ll be talking more about POLST soon. 

           

           

More on Advance Directives

           

Role of Advance Directives

            Some thirty or more years ago, people realized that hospitals and doctors could not appropriately know what treatments patients wanted, especially as they became older and sometimes lost their ability to voice those wishes. Advance directives and living wills were approved for use by every state government. These were supposed to allow those in the medical field to know what a patient wanted.  They were supposed to open up the lines of communication among the patient, family, and healthcare professionals. However, they did not nothing to address how very uncomfortable patients and families and, sometimes, healthcare professionals were to discuss such taboo subjects as death. 

Research with Advance Directives

            In reviewing every study involving the use of advance directives, the dismal results are always the same.  They simply do not work. Why? First of all, only about 20 percent of older Americans even have advance directives. That leaves the vast majority of older Americans, 80 percent, with no written instructions on the care they want to receive near the end of life. 

            In studies on the 20 percent of Americans that have advance directives, they are almost never followed. Why? Of the minority of people that have them, once they are completed, the papers go into hiding, perhaps a safety deposit box. Certainly, no place that a healthcare provider has access to, especially in an emergency. Then, the patients forget or never really think of the need to share this information with family, those members who would need to make critical medical decisions on their behalf. During a crisis or emergency, family members are often left in a quandary. 

What Happens With No Decision

            These families are left feeling unsure of any decision and by not making any decision; the default decision is full aggressive treatment. The loved one ends up intubated, with several tubes that they may not have wanted, in intensive care, until the family can discuss at length what mom or dad or grandpop would have wanted. 

            One day when walking onto the inpatient oncology unit I worked on, I found the staff disgruntled. An elderly patient, dying of end stage heart failure, was at the core of the dilemma. The elderly patient, like most elderly patients, had no advance directives. Although he was dying, his family had to agree to a DNR or Do Not Resuscitate order in order to let him go. Five times that day the family had signed the DNR form and then five times they rescinded their agreement. As more family members appeared, more arguments ensued. Some family members felt that they were ‘playing God’ by signing such a form. Other family members argued that he wanted to go peacefully. We called his doctor to come and hold a family meeting to discuss his options.  Finally, the family agreed, the DNR form was signed, comfort measures were started, and the patient died peaceably a few hours later. 

            But, who wants to put their family through such an ordeal?

Why Advance Directives Don't Work for the Elderly

Let’s begin by defining what an advance directive is. All states recognize the legality of Advance Directives.

·         Living Will – A written document that specifies what types of medical treatment are wanted or not wanted, for example, CPR, use of a ventilator to breathe.  

·         Health Care Proxy – This designates an individual to make health care decisions if you are unable to do so.

·         Durable Power of Attorney – This allows a named individual to make bank transactions, apply for disability, write checks, and sign Social Security checks etc when you are medical incapacitated. (Medicine.net, 2008)

                                                               

A Typical ER Visit with an Elderly Sick Patient

An elderly, ill patient is brought in from home. The patient is sick, over 90 years old with multiple medical problems. Due to dehydration, as well as progressive dementia, the patient is unable to carry on a logical conversation. The family is asked if the patient has a living will or an advance directive, something in writing that tells us how aggressive she wants us to be in caring for her.

Occasionally, the family tells us, “Yes, she has one”. The next obvious question is, “Can we see it?” The family never has it with them and always asks surprised that we would even expect them to have it with them when bringing in an elderly, sick loved one to the emergency room. Then, we go on to ask, “What does the living will say? Does your mom want us to pound on her chest if her heart stops, breaking nearly every rib within a minute?” No, of course, that is not what we really say. What we really say is much more tactful than that. We try several times to “get it out of the family member” what aggressive treatment the patient actually wants. Meanwhile, we have already started aggressive treatment because no family member brought the living will/advance directives to the hospital.

“I Don’t Want that Responsibility”

            We now need to discuss what level of aggressive treatment this family wants or does not want for the loved one they brought into the ER. We ask, “have you discussed what your mom at the end of her life?” Again, most of the time, the family looks like a deer caught in the headlights of a speeding car on a dark night. “No, we haven’t yet”. Well, we need to do that now.  Most family members do not want to take on the responsibility of saying no to aggressive, painful treatment for their loved one. This is sad because we can make someone comfortable at the end of her life. We know how to do that. We also know how to prolong someone’s life yet we cannot give a 90 plus year old back the quality of life she had. So, the patient continues to suffer until the family decides they do not want to see their loved one suffer any more.