Friday, February 17, 2012

Is it Time for Marge to do a POLST?

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.

5 comments:

  1. We don't use the POLST or MOLST in my state. Pity.

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    1. Many states are in the process of getting the POLST in place and more are coming on line all the time. You can check this out on the POLST web site and perhaps volunteer to help out in your state if there's activity! Hope it happens.

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    2. Wow, that site is fascinating. I wrongly assumed that most of the nation was using the standardized form. And the last activity in my state was 2007, with no current contact information listed.

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  2. Hello,

    My dad was in hospice home care. He was admitted for "failure to thrive." While still completely lucid, the records reflect he said to a hospice nurse, "I am not in pain. Get away from me. Get out of my house." He was refusing to take the morphine. He was a physician who specialized in substance abuse, so he knew perfectly well that morphine could kill him. Hospice responded by stating, "The family, not the patient, decides whether morphine is necessary."

    The next day, the records reflect my dad was striking out at the people giving him morphine, using his wheelchair to try to push them away, and the "caregiver managed to get the patient under control with medications."

    He died the next day with what an expert has stated was "morphine toxicity that contributed to and hastened his death."

    My sister was his health care proxy, but we were not told he was in hospice so we didn't know.

    The two people responsible for administering the morphine were his wife, and her boyfriend. They are currently the focus of an ongoing death investigation, in part because of forged life insurance policies, drained accounts, etc.

    Records reflect that 20ml of morphine is unaccounted for 2 days before death. Yet hospice prescribed more.

    I want to do something about this. What can I do?

    I believe hospice broke the law and my dad had a right to refuse to take morphine. They were negligent when 2/3 of a vial of morphine is unaccounted for, and they prescribed more.

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    1. Sorry to hear about your dad's passing. I can't really comment on the complex issues you raise. You could ask to meet with hospice, the doctors involved - and hopefully have all the family there. If you feel the law was broken you might look into having a legal review done. In a general sense, patients make the decisions until they are declared incompetent. At that point the durable power of attorney for health care is the decision maker, but should always try to reflect the wishes of the patient. Hospice is a specific medicare funded program which provides care for patients deemed to be in their last six months of life. My experience with hospice is that they provide superb care for comfort. At times medications are needed including sedatives and morphine - with the goal of comfort, not speeding up the patient's death.

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