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
(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 New Jersey
(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
(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.
[v] A
SPECIAL REPORT, …
[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.