Schiavo-type uncertainty can be avoided

In response to a 911 call in the middle of the night, David, a 79-year-old man with pneumonia, is rushed from a nursing facility to the hospital. His distraught family arrives hours later, horrified to find their father on a ventilator in the intensive care unit. David had completed an advance directive explicitly stating that he did not want aggressive, life-sustaining treatment of any kind.

Unfortunately, David’s advance directive did not accompany him to the hospital.

David is fictitious, but his hypothetical story is real and too common in the United States. Many people worry that their end-of-life wishes will not be followed – whether those are wishes to limit care or wishes to receive all treatments available. Four years ago in a Spokane public forum, a middle-aged man demanded to know what he needed to do to ensure that doctors would honor his wishes. He insisted that he was willing to have his chest tattooed with “Do Not Resuscitate” if that would guarantee no aggressive measures.

That forum, sponsored by the Regional Ethics Network of Eastern Washington (RENEW), led to the development and statewide implementation of the Physician Orders for Life-Sustaining Treatment, or POLST. The POLST form is a standardized form designed to improve end-of-life care. It goes beyond resuscitation orders to include directions regarding comfort measures, IV fluids, and the use of antibiotics.

This valuable tool has two advantages. First, it converts patient wishes for life-sustaining treatment into concrete physician’s orders. These orders provide direction for emergency medical technicians who may be called to a patient’s home or to a nursing home, for emergency room physicians, and for other staff caring for a patient.

The second advantage is that the form is meant to remain with the patient, like a driver’s license or other essential identification. When a patient moves from one health care facility to another, the POLST form goes too. Because health-care facilities throughout the state recognize the form, patients and physicians do not need to complete advance planning documents in each facility.

The original POLST form was developed in Oregon in 1991. RENEW has worked with key stakeholders at the Department of Health, the Washington State Hospital Association, the Department of Social and Health Services and the Washington State Medical Association as well — as with health care administrators and professionals throughout the state — to adapt the POLST form to our own state regulations and laws. From a pilot program in Spokane and Whitman counties in fall 2000 to a statewide, county-by-county “roll-out” of the form in 2002, RENEW has relied upon a grassroots networking approach. Statewide evaluation of the use of POLST led to revisions of the form last fall.

Who should have a POLST form? Health care providers should consider discussing the form with any patient that they think might die within the year. In addition, anyone who chooses not to be resuscitated — a “no code” — or who wishes to die a natural death, or who wishes to specifically direct emergency medical care, should also consider completing the form.

The form lists several options. Some persons, like David, may opt not to be resuscitated in the event of a cardiac arrest. Some may also choose not to be placed on a ventilator or not to receive IV fluids. Others may choose all of these interventions. But regardless of a person’s choices, health care staff will always promote the patient’s comfort. “No code” does not mean “no care.” No patient will be abandoned or ignored. Every patient will be supported.

Patients interested in the POLST form should request it from their health care provider. The form requires the signature of a physician, nurse practitioner or physician’s assistant, along with the patient’s signature or his or her legal surrogate decision maker. The POLST form can provide a valuable opportunity for patients and their families to dialogue with their health care providers about their concerns and questions regarding end-of-life care.

When completed, the bright green form should be posted on a patient’s refrigerator or in another prominent place so that it will be seen easily by emergency medical crew. Health care professionals can order POLST forms online at www.wsma.org/ patients/ brochures.html or by calling toll-free 800-552-0612. More information about the POLST program can be found at the Washington State Medical Association’s Web site at, http://www.wsma. org/patients/polst.html.

POLST forms speak for patients like Terri Schiavo when they are unable to speak for themselves. Fortunately, with a POLST form, tattoos are not needed in Washington state.