Is POLST legal?

           POLST (Physician Orders for Life Sustaining Treatment) is a legally acceptable form that clears states what treatment a patient and family want toward the end of life. POLST started over 20 years ago in Oregon when the state passed legislation creating POLST. Since then, very slowly a handful of states have adopted regulations or laws endorsing the use of POLST to ensure that patient’s end of life decisions are honored. 

Does your state endorse POLST?

            Remembering that POLST does not address all people who face end of life issues such as the otherwise healthy person involved in a traumatic event, its purpose is to address the many who know that the end is coming. Most of this population involved the elderly with multiple medical issues that will eventually lead to death. 

            As we live in a very litigious society, extensive, aggressive medical care is still the norm across the country even when the outcome will still be the same. Perhaps, even more importantly, these invasive procedures continue to occur even though it means that the patient spends his or her last days suffering, in pain, not surrounded by those who love them. 

            The only way to ensure that your loved one’s last wishes are honored is if you live in a state that has endorsed POLST. Some states have made some changes.  For example in the state of New York, it is referred to as MOLST (Medical Orders for Life Sustaining Treatment). In West Virginia, the program is simply called POST (Physician Orders for Sustaining Treatment). 

What matters most is if you live in a state that has a legally endorsed POLST program. If you are interested, please visit POLST.ORG to see if your state has such a program or what you can do to encourage one be started. 

What’s most important is honoring our loved one’s 

LAST WISHES.

What can we do to ensure those we love have their last wishes honored?

           One thing we know for sure is that we are born, we pay taxes, and then we die. Surely, this is life’s cycle. Yet, we are so uncomfortable to address end of life issues. What happens then is that those who are facing the end of life do so alone. We know that there are better ways. As we have been discussing the use of POLST (Physician Orders for Life Sustaining Treatment), there is a better way to ensure that those we love and care for have their last wishes honored. 

As a family member, what can I do?

            Family members need to be aware of the health of their aged, loved one. Discuss openly end of life issues. Do not be afraid to bring up the subject of death. We all think about it. We just may not be comfortable talking about it. While your loved one still is coherent and able to express his or her thoughts on end of life is the ideal time to discuss death. This way you can ensure that you know your loved one’s decisions and not have to guess when the time comes.

            This should not be just one conversation but a series of conversations. These conversations should include your aged loved one, the family, the physician or healthcare team, and your spiritual advisors. All major religions accept the concept of comfort care but the family and aged one may not know this. 

What’s next?

            Only after careful consideration and discussion should a POLST form be completed. Everyone needs to be “in the loop”. This is not a time not to share. All family members should have a copy of the completed POLST form with the original with the aged family member at all times. This way there are no surprises and everyone understands and can honor the loved one’s decisions. Too often, family members say that they have never discussed end of life. Too often, this leads to bickering, disagreements, and frustration among family members because they simply do not know what to do.

            Our society seems to think that the best thing often is to “do everything”. However, as mentioned in earlier posts, doing many invasive procedures may extend an aged person’s life but does not nothing to improve his or her quality of life. In fact, the invasive medical care that we provide often results in increased pain for that loved one. 

            So, take the time now to begin the discussion. You and your aged, loved one will be glad you did. Which way do you want to your aged family member's last memories to be?  

Why Does POLST Work?

The most important aspect of POLST (Physician Orders for Life Sustaining Treatment) is that they work. Living wills and advance directives lack the teeth to be effective. One of the major differences with POLST is that they must be signed by a medical professional. So far, no litigation has come from use of POLST. Most likely, this is due to several factors. 

Since they must be signed by a physician, nurse practitioner, or physician assistant, they are legal documents. The POLST form takes on the same validity as does any doctor’s prescription or written order. Additionally, the form is then signed either by the patient or a family member. This assures that the patient and next-of-kin are in agreement with these orders. Therefore, unlike the ambiguity that comes with the use of living wills, POLST offers a clear cut method of stating the patient’s end of life decisions. 

How the law fits in with POLST

Sadly, there are numerous examples of families disputing the enforcement of living wills. This is why when an elderly patient comes in via ambulance from a nursing home, the emergency physician never looks at a living will, assuming that this patient is one of only 20 percent of the elderly that has one, and decides to enforce it. In most states, including Pennsylvania, living wills do not have to be notarized. This allows for the possibility that the living will could be illegitimate. 

The possibility that multiple living wills exist with different end of life decisions noted. With the use of POLST, the signed original copy must always accompany the patient. In the event that the patient or family chooses to change the POLST form, the originally POLST form must be voided. Only then can a new POLST be created. This assures that the current wishes of the patient and family are honored. 

What is the bottom line with POLST?

     In every study done since the inception of POLST over twenty years ago, patients and families report favorably on its use. Again, in every study using POLST, patient and family end of life decisions are honored over 90 percent of the time, often 99 percent of the time. Comparatively, in studies with the use of living wills, they show almost zero compliance. 

      We all die. However, what we can do for our loved ones is help to ensure that they are comfortable at the end of life.  Most older Americans prefer to die in the surroundings that they live in, whether it is at home, in hospice, in a nursing home. They do not want to go to a hospital for their last breath. With POLST, we can ensure that we do honor their last wishes. 

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.