Clarifying Patients' Wishes: New End-of-Life Measure Quietly Sweeps the US
The emergency call came in at 10:47 on a Saturday night: "Woman in Overland Park with difficulty breathing. Code one closest."
Angela Fera, a paramedic in Johnson County, Kan., and her partner raced to the house, sirens blaring. When they arrived, six minutes after the first dispatch, a man told them that his 62-year old wife had terminal cancer and was unconscious. The paramedics found her sitting upright in bed, ghostly pale with a weak pulse and shallow breathing. Death seemed imminent.
The woman was under hospice care, and had signed a “Do Not Resuscitate (DNR)” order. She had made her wishes clear: She did not want to be taken to the hospital if a life-threatening medical emergency arose.
Photo: A "refusal of treatment" form from an ambulance service; photograph taken by Jacob Windham. Wikipedia
But the woman was not in cardiac arrest, the situation specified in the DNR order. Protocol required that Fera try to save her life, probably by inserting a plastic tube into her trachea to restore breathing and transporting her to a hospital, where she’d be put on a ventilator. Fera guessed that was precisely what the woman did not want. But the husband felt that his wife’s children — his stepchildren — should be the ones to decide whether to withhold treatment.
"We were completely fighting all our instincts to jump in and save her, but on the other hand we really wanted to do what was right," Fera recalled.
New End-Of-Life Document
A new end-of-life document, more explicit and binding than a DNR and advanced directives, is designed to clarify patients' wishes — and spare caregivers such as Fera from facing such wrenching choices.
A "physician order for life-sustaining treatment" (POLST) is a medical order, signed by a doctor or other authorized medical provider. The product of a conversation between patient and provider, a POLST specifies a patient’s goals and desires as death closes in. Unlike a traditional DNR, it covers such medical interventions as resuscitation, hospitalization, use of antibiotics, hydration, intubation and mechanical breathing ventilation.
Without much opposition or attention, many states have adopted POLSTs. This year, Indiana and Nevada approved legislation to allow their use, leaving only seven states and the District of Columbia without POLSTs in at least some stage of development.
They tend to come in garish colors — neon pink, orange, and green, for example — so they stand out among other documents in a home. People are encouraged to put them on their refrigerators, and paramedics are trained to look for them there. In Oregon, where POLSTs originated in the early 1990s, they are recorded in an electronic registry so first responders can access them online. Other states are moving in the same direction.
Research suggests POLSTs are effective in matching treatments to patients’ wishes. According to one study, patient preferences noted on POLST forms matched the actual treatment—or non-treatment—in more than nine out of 10 cases.
Vague or Irrelevant
Dr. Susan Tolle, one of the creators of POLST and director of the Center for Ethics in Health Care at the Oregon Health and Science University, said DNRs and other end-of-life documents tend to be vague or irrelevant to many medical situations. In many cases, they are signed by somebody whose authority may be in question during a medical crisis.
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