Marge was aging and gradually “falling apart”, as she would say. “First it was my back, then my knees, and now my heart is giving out”. She confronted her doctor with this in a frustrated manner, “I’m no good for anything anymore. I can’t really enjoy the things I used to. Most of my friends have died off, so maybe I’m next”.
The doctor in sizing up Marge’s advanced age and frailties reviewed her Living Will and Durable Power of Attorney for Health Care. These documents were correctly completed and signed, but what level of care would Marge really want? Her Living Will said she would not want CPR if her heart stopped and doctors felt she was terminally ill, but that wouldn’t really stop Medics summoned by 911 from doing everything until more information could be obtained.
Her doctor explained, “Marge, the documents don’t really tell me whether you would want antibiotics for a pneumonia, whether you would want to exit this world at home or in the hospital, or whether you’d want tube feeding if you are mentally incapacitated. We need to talk about a POLST form to really document what you value!”
“What’s a POLST form”?
“Well, it stands for Physician’s Orders for Life Sustaining Treatment. It gets what you want down in black and white. It will be honored everywhere in the state and get you the care you’ve requested.”
Marge was a little puzzled, “How does it work?”
They spent the next 10 minutes completing Marge’s POLST. Fortunately her daughter was present for the conversation. Marge confirmed she did not want CPR under any circumstances. The second and really more important part of the form dealt with the level of care she would want. She still valued life and would want to go to the hospital if that helped, have antibiotics, and even artificial fluids and nutrition. But there were limits, “Doctor, if I have a stroke or dementia or am otherwise not with it, then I’d want comfort measures only.”
Marge took this co-signed document home after leaving a copy at the doctor’s office. It was to be submitted by the doctor to a registry. At home it was placed on the refrigerator and copies given to close family members. All in all, Marge felt that she was now in more control of her own destiny.
Comment: I attended the National POLST conference in San Diego recently and was most impressed at the leadership of Oregon State in disseminating expertise to other states. There are communication, legal, legislative, and medical issues unique to each state. Now a majority of the states have programs in place. The registry created in Oregon is allowing research for the first time on the effectiveness of the POLST document and helping direct quality improvement efforts. The research letter recently published in JAMA by Dr. Susan Tolle’s group is showing the way toward the future. Since CPR is generally ineffective in patients with advanced illness, the question about CPR isn’t the most important one. More importantly the patient’s wishes about quality of life and level of care need to be explored and documented. The POLST document is most appropriate for those in the last year of their life or for the very frail elderly when their wishes and values are clear. Having the POLST conversation is something we all need to learn and do well.
Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.
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