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.

 

Choices

We are all getting older

            As a nation, soon 20 percent of our American population will be over 65.  While that is really not so old, in a few years, 20 percent of our population will be over 80 years old. Certainly, there are some Americans who chose healthy, life-long habits such as not smoking, exercising regularly, drinking lots of water daily, eating a diet high in fiber, fruits, and vegetables. However, many have chosen not to take self-responsibility for their health. Aging itself takes a toll on your health. Major organs such as the liver and kidneys just do not work as well. Now, for those who have made healthy choices and continue to be active, both physically and mentally, their bodies adapt and they enjoy a decent level of health. 

What the studies tell us about aging and health 

            Anyone remember your mom saying, “You are what you eat!” This might have been when you were choosing those ding-dongs (chocolate dipped cupcakes) and soda, and passing up an apple with a smidgen of peanut butter with a glass of low fat milk. Research shows that so many disease processes are linked to our diets. We really are what we eat!

 

Just one example ...

            When someone in their forties or older comes in to the emergency room, complaining of left abdominal pain, do you know what it is from? Diverticulitis ... when diverticula in the digestive tract becomes inflamed or infected. Diverticula are bulging pouches that form in the digestive system, usually in the large intestines. Why does this happen? Because the person already has Diverticulosis...those pouches that formed in the intestines. Those pouches form simply because a person is not eating a high fiber diet, rich with grains, fruits, and vegetables, staying well hydrated (for most of us that means drinking 8 glasses of water daily), and regularly exercising.

            In other words, we eat every day; therefore, we need to poop every day. It is when those waste products stay in the intestines too long, that the pouches begin to form. Then, eating certain foods, particularly with seeds, such as tomatoes, popcorn, or strawberries, and the seeds can become embedded in the pouches and a full-fledged infection begins.  After the initial episodes of diverticulitis where one rests the digestive tract with only clear liquids, the diet then needs to be rich in high fiber foods for the rest of that person’s life. There was a 17 year study published on this recently that showed it is okay to eat foods with seeds as long as it is part of a high fiber diet.

What can you do?

            Encourage those who you love to make healthy life style choices and lead by example yourself. This will help you and those you love enter that 80 plus crowd in a healthy state, allowing you and loved ones time to discuss those end of life plans.