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Ahearn: N.J. to help end-of-life patients choose care

By James Ahearn
January 3, 2012

NEW JERSEY has joined more than 30 other states seeking to help end-of-life patients and their families determine what kind of care they receive.

Is it to include all means necessary to keep the patient breathing, even if he or she loses consciousness permanently? Or is the goal to limit pain and keep the patient as comfortable as possible as the inevitable end approaches?

How about donation of organs? How about financial considerations? Suppose that yet another surgical procedure might extend life by a month or so, but at a cost of tens of thousands of dollars? What then?

New Jersey encourages patients to prepare advance directives, also called living wills, setting forth their preferences on such matters and appointing someone, typically the spouse or an adult son or daughter, to make decisions when the patient cannot do so.

However, even though forms for the purpose are available for free, many people, probably a majority, have not prepared one. They would just as soon not think about such matters. Or they rely on a letter that Grandma wrote years ago that doesn’t provide guidance on the circumstances that beset her now.

New Jersey is not alone here. Other states face similar problems. But they differ from one another in laws and regulations, so a universal nationwide solution won’t work.

Beginning in 1991, in Oregon, however, a state-level system was developed. It is called POLST, for Physician Orders for Life-Sustaining Treatment.

It is based on effective communication of patient wishes, documented by medical orders written on a common, distinctive, brightly colored form, often pink, and a promise by health care professionals to honor these wishes. The form accompanies the patient from one stage of treatment to another, perhaps from emergency room to hospital bed to hospice.

It can supplement or replace advance directives, at the patient’s option. States commonly recognize as valid POLST forms prepared and signed in other states.

At a glance

At each stage of care, the attending professional, often a senior nurse, can tell with a glance at the form what ailments the patient has and what he or she wants done in an emergency, even if he or she cannot articulate it. And a physician’s order is legally enforceable, more so than a list of preferences in a living will.

Last summer and fall, the Legislature and Governor Christie enacted a law that will establish POLST procedures in New Jersey, as New York and Pennsylvania have already done.

The bill was first passed by each house. The governor returned it with recommended revisions, in a conditional veto. The Legislature accepted his changes without a dissenting vote, and he signed it into law.

The governor dealt with the lawmakers with appropriate and respectful formality. There was no talk this time of jerks and political thugs, terms he has used to dismiss opponents. Instead, he wrote in his conditional veto:

“I commend the sponsors for putting forward legislation that seeks to improve end-of-life care.” The primary sponsors included Sen. Teresa Ruiz, Democrat of Essex County, and Sen. Loretta Weinberg, a Bergen Democrat and frequent critic of the Republican governor.

The veto message continued, “End-of-life care issues are often very complicated, and raise many difficult and emotional issues for patients and their families. Although advance directives provide an important means of ensuring that a patient’s wishes are respected, families and health care professionals are often confronted with the negative consequences of inadequate end-of-life care planning.”

A POLST form can straighten things out, so long as the patient’s wishes are fully respected, Christie continued. However, he wrote, the bill as written would allow those wishes to be overridden by the patient’s physician or health care representative. That was unacceptable, the governor said. He suggested a dozen revisions, some of them single words.

The bill is signed

The Senate accepted the changes by a vote of 37 to 0. In the Assembly, the vote was 67 to 0. Five days later the governor signed the amended bill.

The initiative now passes to the commissioner of Health and Senior Services, Mary O’Dowd. She is to appoint a 21-member panel to implement the new law. It will recommend designs for POLST forms, training of health care professionals and preparation of special forms for patients with mental illness or developmental disability.

More broadly, The Associated Press reports, the panel will conduct a comprehensive review of the quality and cost-effectiveness of end-of-life services and how easily they can be accessed.

The panel will include 14 public members; the state ombudsman for the institutionalized elderly; four legislators, two each from the Senate and the Assembly, split politically, and the commissioner of Human Services and O’Dowd herself. Once the group begins meeting, it will have 18 months to submit its report.

It is a good start to a task whose completion is mandated by simple compassion.