Last week’s column discussed Advance Care Directives for end stage medical treatment. The Directive prepares for the possibility that a person’s future state of permanent unconsciousness could cause an individual to be unable personally to communicate to the treating physician about the care or treatment he or she would like to receive or not to receive. It is an important legal document which provides guidance, but not absolute direction, to the treating physicians.
For an Advance Care Directive to be used by an agent to act on behalf of the principal’s wishes, a physician must have determined that a state of permanent unconsciousness exists, and must have access to both the document and agent. Because an Advance Care Directive does not contain clear direction to medical staff, in most instances, more specific medical direction is needed from the physician.
The Pennsylvania Order for Life Sustaining Treatment (POLST) is a medical order which translates the intentions and wishes of the Advance Care Directive into a medical order that can be implemented. A POLST may be completed by a licensed physician, physician’s assistant or certified registered nurse practitioner.
Unlike an Advance Care Directive, which can vary in format or style if it generally conforms to statutory requirements, a POLST is a specific, fill-in-the-blanks, two-sided, one page form which must be on printed on pink cardstock, and must have original signatures. The idea is that the POLST will be very noticeable in a patient’s medical file, and travel with the patient.
A POLST form is a tool, but use of it is not required. Some physicians and facilities use POLST more than others. General guidance suggests that use of a POLST may be appropriate if a physician reasonably believes that a patient could die from chronic illness or frailty within one year. Discussion of treatment options, including those reflected in an Advance Care Directive, is required with the patient or the agent named by the Directive, and a signature to evidence that discussion is required to be entered on the POLST.
POLST is the primary form, but not the only medical form, to give medical directions for end of life treatment In Pennsylvania. An out-of-hospital do-not-resuscitate (DNR) order instructs an Emergency Medical Technician (EMT) not to perform cardiopulmonary resuscitation (CPR) on an individual who is carrying such a paper order or is wearing a prescribed DNR necklace or bracelet. This DNR process pre-existed the POLST form, and if such a DNR does not exist, the POLST form must be supported by an immediate order to stop an EMT from performing CPR. Without a DNR or an order from a doctor, once an ambulance has been called, the EMT has a duty to use CPR and other means to stabilize life and get the patient to the emergency room.
Without such an out-of-hospital DNR form, bracelet or necklace, the fact that a DNR was taped to the door of a hospital room does not mean that it can be considered to be a continuing order after a patient is discharged. Certainly, the Advance Care Directive itself is never a DNR, which is a common misunderstanding among those who say, “I went to my lawyer and got a DNR.” This can be confusing and upsetting to family members who have been instructed by their frail loved one to “avoid heroics and let me go when the time comes.”
It is difficult for a physician to issue a POLST to withhold treatment if the Advanced Care Directive is not clear, or if multiple family members are empowered as agents and the family is not united. Even an incompetent principal may countermand a decision made by the principal’s agent that would withhold or withdraw life sustaining treatment at any time and in any manner by informing the attending physician, or if the terminal principal has severe dementia but occasionally makes a semi-coherent statement about wanting to live.
“One of the most difficult issues I face as a physician is when a patient is facing an end stage condition, and the family has not prepared in advance and feels conflicted among one another,” says Dr. George P. Branscum Jr., MD, who is the medical director of Sarah A. Todd Memorial Home, the Thornwald Home and the Chapel Pointe Retirement Center. “I consider discussion of end of life decisions with patients and all family members to be a good way to avoid conflicts when a patient’s condition reaches a critical stage.”
If the family cannot effectively serve as a patient’s advocate, physicians such as Dr. Branscum on occasion can seek input from a healthcare facility’s ethics committee. Such a committee includes the physician, nursing staff, a pastor or chaplain, the principal’s health care agent and a lawyer. An ethics committee can meet on short notice to resolve ambiguity, but a decision to withhold treatment ultimately requires an agent’s consent, if not proactive advocacy.
Life or death decisions are not easy, but advance discussion and planning is useful, if not required, to avoid emotional turmoil and family dissension. You, as a principal, should begin now by getting help from an experienced lawyer to counsel you and your agent in the preparation of an Advance Care Directive. The Directive and your family’s understanding of it will facilitate a physician’s ability later to give directions with a POLST, or to issue a DNR when the time comes, if you prefer to leave this world as peacefully as possible after it has been determined that you are permanently unconscious and the quality of your life has ended irreversibly.