Financially Speaking Podcast

New Efforts to Simplify End-of-Life Care Wishes

Published on April 13, 2011

By Laura Landro, Wall St. Journal, March 15, 2011

Advance directives, which allow people to plan ahead for end-of-life care, can be too vague to cover many medical situations. Now, a growing number of states are promoting another program to help guide physicians with a patient's specific instructions.  The programs are known as Physician Orders for Life-Sustaining Treatment, or POLST. They are meant to complement advance directives, sometimes known as living wills, in which people state in broad terms how much medical intervention they will want when their condition no longer allows them to communicate. A POLST, which is signed by both the patient and the doctor, spells out such choices as whether a patient wants to be on a mechanical breathing machine or feeding tube and receive antibiotics.

POLST programs are currently in use in 14 states and regions… and another 16 states and six regions are developing programs [including Texas and Louisiana]. Besides providing documents that meet local regulations, the programs train health-care providers to discuss end-of-life treatment choices with patients with terminal illness or anyone wishing to define their care preferences.

"More than 75% of people will be unable to make some or all of their own medical decisions at the end of life, but we don't prepare patients and their families to deal with this situation, and it's frightening and difficult for them to know what to do," says Rebecca Sudore, a physician at the University of California, San Francisco and the city's VA Medical Center.

Planning ahead for end-of-life care is meant to allow patients to reduce the amount of medical intervention, if that's what they prefer. But patients also can make clear their wishes if they prefer maximum intervention.  A POLST form is an official medical order, says Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health & Science University, a developer of the POLST program. Unlike an advance directive, which can be misplaced or vaguely worded, a POLST spells out specific treatment instructions and remains part of a patient's medical record.  States that have adopted the POLST program also have put in place general protections for medical personnel who follow the directives. 

Advance directives, which also allow people to designate a surrogate to make decisions about care, vary state by state. While some states' forms may be highly specific, they may be printed out and stored somewhere where they can't be found when needed.

A study supported by the National Institutes of Health last year found that patients with POLST forms were more likely to have treatment preferences documented than patients who used traditional documents such as living wills and do-not-resuscitate orders.  Making end-of-life decisions when a loved one's wishes are not known can be difficult for families.

After years of struggling with Parkinson's disease and congestive heart failure, Nancy Williamson's mother became seriously ill last August and slipped into a coma from which doctors said she would never recover. Although Ms. Williamson and her sisters wanted doctors to do more, they learned that their mother had signed a POLST form asking for only limited medical treatment.  Ms. Williamson, a California lawyer, says that after arguing with doctors because she wanted to hold on to her mother, "I realized having the POLST made it easier for us because my mom had made her own health-care decisions." The experience led her to help clients prepare end-of-life documents, Ms. Williamson says.

Tags: living will; end of life; advance directives, A

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