End-of-Life Choice, Palliative Care and Counseling

Posts Tagged ‘POLST’

Jun 22, 2012How Do You Guide Your End-of-Life Medical Care?

By Moorestown Patch Staff
Moorestown Patch
June 20, 2012

William P. Isele, Esq. is of counsel to Archer & Greiner, P.C., where he practices health care law and elder law. He is a past chair of the New Jersey State Bar Association Health Law Section, and current chair of the NJSBA Elder & Disability Law Section. From 1999-2007, he served as New Jersey’s ombudsman for the institutionalized elderly.

Q. I have an Advance Health Care Directive to guide decisions about my medical care in case I can’t make the decisions myself. How can I be sure my wishes will be honored if and when the time comes?
A. Good for you! You’ve taken the first important step in exercising your right of self-determination with regard to end-of-life care. An Advance Directive, coupled with a health care power-of-attorney or proxy directive, lets your caregivers know your wishes regarding your treatment, and authorizes someone else to speak for you—if you are unable. Soon, New Jersey residents will have an additional tool to assure our treatment goals and directions are followed.

Last year, Gov. Christie signed into law bipartisan legislation creating a POLST—Physician Orders for Life-Sustaining Treatment—program in New Jersey.

The centerpiece of the POLST program is a written form that converts a person’s wishes regarding medical treatment into a medical order. The POLST form will contain immediately actionable, signed medical orders, which apply across the health care spectrum: in hospitals, nursing homes, and even to emergency care personnel. The form itself is an easily identifiable document, typically brightly colored in order to stand out from the rest of the patient’s medical record. The New Jersey POLST form is expected to be in use within a year.

Comparison to Advance Directives
POLST is intended to be a complement to Advance Directives. Whereas an Advance Directive expresses an individual’s wishes regarding future health care issues, POLST can provide clear instructions regarding a current medical condition. An Advance Directive is necessary to appoint a legal health care representative or proxy, since such designation is personal, and not in the nature of a medical order. A POLST form should accompany an Advance Directive when appropriate. Most importantly, an Advance Directive may not guide actions by emergency care personnel when it is produced outside of an institutional setting, such as a hospital. Because POLST is a medical order, it is specifically intended to provide direction to emergency care personnel.

Simply put, an Advance Directive is a document an adult can use to express his/her desires regarding end-of-life decision making. It does not have the same authority as a POLST, since it is not a medical order. The POLST document is a medical order health care workers must follow. Because they serve different purposes, it is recommended patients have both documents.

One of the concerns identified in the past regarding the use of Advance Directives was physicians were not always well-trained in dealing with end-of-life decision making. In a very significant provision, the New Jersey Legislature has required that the continuing education provisions applicable to physicians and advanced practice nurses (APN) include at least two credits of educational programs or topics related to end-of-life care.

The law requires the commissioner of health to designate a Patient Safety Organization (PSO) operating pursuant to the Federal “Patient Safety and Quality Improvement Act of 2005” to prescribe the form for use in New Jersey; to define the procedures for completion, modification and revocation of the form; and to provide ongoing training for health professionals in the use of the form. The commissioner has selected the Institute for Quality and Patient Safety at the New Jersey Hospital Association as the PSO to function in this regard. It’s expected the Institute will have finalized the POLST form for use in New Jersey by the end of 2012.

Valid POLST Form
A POLST form is considered completed, and therefore valid, if it contains information indicating a patient’s health care preferences; has been voluntarily signed by a patient with decision-making capacity, or by the patient’s representative in accordance with the patient’s known preferences or in the best interests of the patient; and includes the signature of the patient’s attending physician or APN and the date of that signature. A document executed in another state, which meets the requirements of the New Jersey act for a POLST form, shall be deemed to be completed and valid to the same extent as a POLST form completed in New Jersey.

Modifications
It is, of course, possible that the treatment goals of a patient may change. The act permits the patient’s attending physician or APN, after evaluating the patient and obtaining the informed consent of the patient or patient’s representative, if so authorized, to issue a new order, which modifies or supersedes the original POLST. At any time, a patient with decision-making capacity may modify or revoke the POLST, or request alternative treatment.

The POLST form gives the patient the choice to authorize a representative to revoke or modify the patient’s completed POLST form if the patient loses decision-making capacity. If the patient authorizes his/her representative, the representative may, at any time after the patient loses decision-making capacity, and after consultation with the patient’s attending physician or APN, request the physician or APN modify or revoke the completed POLST form, or otherwise request alternative treatment.

In the event of a disagreement between or among the patient, his/her representative and the attending physician or APN, the parties may turn to procedures and practices established by a health care institution, such as consultation with an ethics committee, or may seek resolution in court.

Patient and Provider Rights
The law preserves a patient’s right to refuse treatment, and does not require health care professionals or emergency care providers to act contrary to law or medical standards. Private, religiously-affiliated institutions are not required to act contrary to their policies or practices, as long as such policies and practices are properly communicated, and the patient is not abandoned or treated disrespectfully.

Conclusion
POLST is the next step in a maturing approach to end-of-life care. It is a vehicle for patients and their health care providers to spell out for both caregivers and family members the patient’s health care goals. The experience of other states has been that POLST is followed by other caregivers. Although not bound by medical orders in the same way as health professionals, family members can be more comfortable with a decision, knowing their loved one actively participated in the process. And finally, POLST will empower patients. Additional information about POLST can be found at www.POLST.org.

DISCLAIMER: Information provided in “Ask the Lawyer” is for general informational and educational purposes only. It does not constitute legal advice, and may not be used and relied upon as a substitute for legal advice regarding a specific legal issue or problem. Transmission of the information is not intended to create, and receipt does not constitute, a lawyer-client relationship. Legal advice should be obtained from a qualified attorney licensed to practice in the jurisdiction where that legal advice is sought.

Jul 2, 2009Everyone Needs an End of Life POLST

[Originally published at The Lund Report]

Creating a conversation about the end of life
By: Carla Axtman

July 1, 2009 — Serious illness, death and dying are often difficult subjects to talk about. However, a lack of communication among individuals, families and health care professionals on these matters often leads to distress for both patients and their families.

As individuals approach the end of their lives, more should be done to facilitate communication with patients and their healthcare providers. These discussions are critical for patients to learn and understand all their treatment options. In addition, physicians and other healthcare providers can learn and understand what their patients want for themselves in terms of the care they want or do not want to receive.

The Physician Order for Life Sustaining Treatment (POLST) is one way to get these conversations started. POLST forms allow patients to document with their physician their end-of-life treatment wishes. A decade of research has demonstrated that orders for life-sustaining treatment effectively convey treatment preferences and guide medical personnel to provide or withhold interventions. These orders contain the individual’s treatment decisions, signed by a physician, and follow the patient through all end-of-life healthcare settings. Without these medical orders, emergency medical personnel may be required to provide treatments that aren’t consistent with the individual’s preferences.

Compassion & Choices is the nation’s leading nonprofit organization working to improve care and expand choice at the end of life. C&C strongly believes that health care should focus on the needs and desires of the patient. A patient-centered system is not only fiscally responsible, but it also empowers the patient to control his or her own healthcare. It is the patient’s right and responsibility to determine the healthcare they want that’s in line with their values and beliefs.

Currently, only half of terminally ill patients have conversations with their physicians regarding end-of-life treatment choices such as hospice care or other end-of-life care preferences. Americans tend to put off having these conversations on death and dying. As a result there is often a lack of planning for care at the end of life. If a health crisis then occurs, the patient can be subjected to unwanted, futile and often painful medical procedures. This kind of care doesn’t necessarily reflect the individual’s values, beliefs or informed choices but is a “default” approach that kicks in when patient’s wishes are unclear.

Dying individuals have the right to decide whether to stay in the acute care system or to enter hospice. The acute care system continues to aggressively treat patients up to the end of life, even with side effects that may shorten or weaken that life. When death arrives, heroic measures are used in an attempt to wrest them back to life.

In the hospice system, pain and anxiety are managed. Appetite stimulants are given if needed. Patients receive the food and fluids that they enjoy and that their body can manage. Treatments and medications with difficult side effects that they can’t stand and won’t save their life are withdrawn. Ironically, this type of care is the most likely to prolong a patient’s life and improve the quality. In hospice care, individuals can have a peaceful death without the trauma of heroic measures.

A study of 323 cancer patients who had died found that those who had end-of-life talks were three times less likely to spend their final weeks in intensive care. These patients were also four times less likely to be on breathing machines and six times less likely to be resuscitated. The study found that aggressive care is associated with a worsened patient quality of life and a more difficult bereavement adjustment.

Billions of dollars are spent each year in the U.S. on intensive treatment for older patients in the last six months of life. Terminally ill patients who talk with their doctors about end-of-life treatments can extend and improve their quality of life without extravagant expense while achieving a more peaceful death. Patients who have the discussion tend to opt for palliative care in a hospice or at home rather than aggressive and expensive treatments like emergency resuscitation, ventilators and intensive care units.

Patients deserve to know their end-of-life treatment options. Making informed choices is the key to a peaceful and dignified death. POLST conversations are one of the most effective ways to facilitate these discussions both with physicians and with family.

Carla Axtman is the online community builder for Compassion & Choices

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