Monday, September 2, 2013

POLST: What is it and why should you oppose it?

By Julie Grimstad

The POLST (Physician Orders for Life-Sustaining Treatment) form is a standard document that, when signed by a designated healthcare professional, dictates whether to withhold or administer certain forms of medical treatment and/or care. POLST is known by different acronyms in various states (MOST, MOLST, POST, etc.). 

A brightly colored form that is very visible in a patient's medical chart, POLST has boxes to check off indicating that a patient does or does not want cardiopulmonary resuscitation (CPR), antibiotics, nutrition and hydration, etc. Trained "facilitators"—usually not physicians—discuss treatment options with patients. After filling out the form with a patient, the facilitator presents it to be signed by a designated healthcare professional—someone who may never have seen or talked to the patient. The completed POLST form is not simply an expression of a patient’s treatment preferences; it is a set of physician's orders which must be followed.

POLST medical orders travel with the patient from one healthcare setting to the next and even home to be followed by EMT's in the event of a medical emergency. The first order in many POLST-type forms is "FIRST follow these orders, THEN contact Physician, Advanced Practice Nurse, or Physician Assistant for further orders if indicated."[i]

POLST is tilted toward non-treatment and can encourage premature withdrawal of treatment from patients who, but for the denial of treatment, would not die. Facilitators present options for treatment as if they are morally neutral, even though certain decisions may lead to euthanasia by omission. Groups that promote euthanasia and assisted suicide, such as Compassion & Choices (formed by the merger of Compassion in Dying—a Hemlock Society spin-off—and End of Life Choices), strongly endorse POLST. This is a big RED FLAG.

Of special concern is a new federal bill – the “Personalize Your Care Act” (H.R. 1173). Introduced by Representative Earl Blumenauer (D-Oregon) on March 14, 2013, it is described as a bill to “amend the Social Security Act to provide for coverage of voluntary advance care planning consultation under Medicare and Medicaid, and for other purposes.” This bill resurrects Blumenauer’s 2009 proposal (dubbed the “death panels” bill by opponents), but with a twist. H.R. 1173 includes funding for promotion of POLST throughout the country. Section 3(a) would direct the Secretary of Health and Human Services to make grants for the purpose of (1) establishing statewide programs for POLST or (2) expanding or enhancing existing programs for POLST.

Section 1(b)(11) declares: “A decade of research has demonstrated that physician orders for life-sustaining treatment effectively convey patient preferences and guide medical personnel toward medical treatment aligned with patient wishes.” But evidence and common sense refute that claim. Consider:

(1)   California Advocates for Nursing Home Reform (CANHR), a nonprofit advocacy group, conducted a survey of long-term-care ombudsmen in California. The resulting report states, “Many times, POLST forms will be accompanied by handouts meant to sway patient decisions. For example, on the POLST form, CPR is an available option. However, accompanying handouts describe how survivors of CPR may have broken ribs and brain damage and that those revived may only survive a short period of time afterwards. The handouts are clearly intended to convince patients or their representatives to forgo CPR.”[ii] The bias against life-sustaining treatments in POLST literature does not foster truly informed consent. Informed consent requires that the patient also be told the possible benefits of treatment, such as recovery.[iii]

(2)   Allegedly designed for use by terminally ill and chronically ill elderly patients who are near the end of their lives, some states have vastly expanded POLST’s reach. Nevada’s statute mandates that doctors must offer a POLST to every individual thought to have five years of life to live and to everyone who is diagnosed with a terminal illness regardless of how many years of life the individual is expected to have ahead of them. And New Jersey recently broadened the scope of POLST to include any person who wishes “to make their preferences concerning life-sustaining treatment or other interventions known in advance.” POLST invites people to make the most consequential decisions of their lives based on future theoretical scenarios which cannot be foreseen with accuracy. Predicting what one will want or need in the future is guesswork. Informed consent requires that each medical decision be made in the context of a patient’s present situation and be based on truthful and complete information presented in a way that patients, agents[iv]  and families can understand.

(3)   CANHR also reported that 59% of surveyed ombudsmen found that POLST forms were “often” or “sometimes” signed by third parties, even when the nursing home resident had the capacity to make health care decisions.[v]  In their medical audits of nursing homes, CANHR found blank POLST forms pre-signed by physicians in the charts of neglected patients.[vi] Some state POLST forms do not require witnesses or even the patient’s signature (e.g., Wisconsin, Oregon). How can we be certain that a POLST form reflects the patient’s own treatment choices rather than someone else’s choices?

(4)   Sec. 1(b)(6) of HR 1173 claims that POLST forms “complement advance directives.” However, in some states, they override wishes expressed by patients in their advance directives or by their agents. If a POLST form and an advance directive conflict, the latest (usually POLST) often controls, even when the patient or agent did not sign the POLST.

POLST is not about ensuring that the medical treatment preferences of patients are known and honored. That can be accomplished by encouraging people to use an advance directive (medical power of attorney) to appoint someone they trust to make medical decisions for them in the event they become incapable of voicing their wishes.[vii]

POLST is not needed to cause treatment to be provided. A typical POLST form, such as the Colorado MOST (Medical Orders for Scope of Treatment), states, “Any section not completed implies full treatment for that section.” Therefore, filling out a POLST form if one wants full treatment is unnecessary.

POLST is a vehicle used to manipulate patients to choose to limit or refuse treatment which they may need in the future. POLST poses a grave risk to the lives of vulnerable patients. That is why POLST must be opposed and Blumenauer’s bill defeated.

About the author: Julie Grimstad has been a volunteer patient advocate for 27 years. She is the executive director of Life is Worth Living, Inc. 

[i] Quote from Colorado Medical Orders for Scope of Treatment (MOST) form.
[ii] A SPECIAL REPORT, California Advocates For Nursing Home Reform (CANHR), Physician Orders for Life-Sustaining Treatment (“POLST”) Problems and Recommendations, 2010.
[iii] Chan, Paul, et al., “Long-Term Outcomes in Elderly Survivors in in-Hospital Cardiac Arrest,” New England Journal of Medicine, 3/14/2013: Nearly 60% of elderly survivors who were resuscitated after cardiac arrest in the hospital were alive after one year. The study’s lead author told the New York Times, 3/14/2013, “We shouldn’t hold a nihilistic attitude toward resuscitating the elderly, given these results.”
[iv] “Agent” means a legal healthcare decision maker appointed via a patient’s advance directive.
[vi] CANHR_Golden_Cross_Physician_Report-2012 BLANK SIGNED POLST.pdf
[vii] The PHA recommends the state-specific Protective Medical Decisions Document (PMDD) formulated by the Patients Rights Council.