Doctor's Order Conveys Dying Wishes

Seattle Times
By Carol M. Ostrom

Eight years ago, when musician Mary Levine decided she wanted to die at home, she worried that a visitor might call 911 when the time came, emergency medical workers would rush in, try to resuscitate her and cart her off to the hospital.

Levine, a strong-willed cancer patient from Seattle, plastered big signs on her front door, her refrigerator and elsewhere in her home: "DO NOT RESUSCITATE! DO NOT CALL 911!"

Today, patients in similar situations have a better option: It's called POLST, a not-so-catchy acronym for "Physician Orders for Life Sustaining Treatment."

When signed by an end-of-life patient and medical provider, it is a "doctor's order" that requires emergency medical workers — as well as medical providers in hospitals or nursing homes — to respect the patient's wishes.

Unlike most other forms directing end-of-life care, the bright-green POLST directs care wherever a patient goes, from home to nursing home to hospital and back again — giving the patient's wishes what one fan of the form calls "power and portability."

Although the form has been around — at least for those who knew it existed — for about five years, the Washington State Medical Association and the Regional Ethics Network of Eastern Washington have launched a campaign to expand its use.

The form also has been newly revised, allowing a physician assistant or nurse practitioner to sign in the doctor's place.

Experts in end-of-life care say patients and doctors are confused about how to best have their wishes respected, and it's no wonder: Over the past decade, a whirlwind of forms has come their way, each with limitations and intended for a specific audience.

Nursing homes, for example, demanded their own "Do Not Resuscitate" forms be filled out by residents. Hospitals had other versions of the form.

Meanwhile, most advisers were telling people they needed a "living will" and a "durable power of attorney for health care" — the forms known collectively as "advanced directives."

But in many emergencies, physicians consider a living will to be advisory, if they consider it at all. The more-powerful durable power of attorney gives someone else authority to make decisions — but only if that person is available and able. In most places, emergency paramedics, who work under the direction of a doctor, can't respect either, because they are not orders from a doctor.

"Advanced directives don't mean piddly squat to the EMS [emergency-medical-services providers] because they aren't MD orders," said Sally Denton, a nursing-home administrator and nurse from Spokane who thinks the new form gives much-needed power to end-of-life patients.

The new form replaces the EMS/No CPR form, which wasn't widely used, and is more comprehensive and specific. For example, a patient can say no to CPR but yes to comfort measures such as oxygen, or treatments such as antibiotics or tube feeding.

And unlike the EMS/No CPR form, POLST can be signed by a mentally incompetent patient's legal decision maker.

The POLST form, modeled on a similar form that had been used in Oregon for about a decade, is meant to solve the gaps and inconsistencies that have left terminally ill or end-of-life patients without sufficient protection, Denton said.

"Until you have walked in our shoes, you don't realize how many near misses there have been — almost resuscitating someone who didn't want to be resuscitated, because we didn't have the right paperwork," she said.

Denton still remembers the anger of many older patients who turned up at a forum as the POLST form was being developed. They were angry that their advanced directives or those of family members had not been followed by emergency workers or hospitals, she recalled. "One man said, 'What do I need — a tattoo on my chest?' They had horror stories to back up their anger."

For a patient, Denton said, the new form is power: "It's like a suit of armor," she said, making sure that all medical workers, in all settings, respect the patient's wishes.

"The importance of this form, in protecting people's choices in how they want to die, is huge," said Dr. John Osborn, a Spokane internist who has been active in the POLST effort. "POLST also provides a point of entry for people to talk about their end-of-life choices with their doctor — it's a valuable way to have a discussion about what people want."

About POLST: A free online video, "POLST: Choices for End of Life," is available at the Washington State Medical Association. (Windows Media Player for Windows or Macintosh is required to view).

For patients: POLST forms can only be obtained from your physician, who can order forms from the Washington State Medical Association. View a sample form.
Patients are not allowed to download or order forms themselves.

For NP, MD, PA: These forms are actually available for download here. There is a specific type and color of paper they want it printed on. If you choose, you can also order pre-printed quantities.
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