Will POLST integrate end-of-life care options?
A recent investigation (PDF) of state statutes and legislation affecting the ability to implement a nation-wide program to standardize medical orders reflecting individual patients’ end-of-life treatment preferences was made publicly available by Oregon Health & Science University.
The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm Program was developed in Oregon and strives to increase adherence to patient preferences throughout the health care system by providing immediately actionable medical orders on a “standardized, brightly colored form that provides specific treatment orders for cardiopulmonary resuscitation, medical interventions, artificial nutrition, and antibiotics” (p. 119). Ineed, the POLST form more accurately represents patients’ end-of-life preferences than traditional advance directives and DNR (do not resuscitate) orders because the patient completes it in collaboration with health care professionals and any proxy decision makers.
Many states have implemented (Oregon, Washington, West Virginia, New York, and Wisconsin), or are developing (Texas, Louisiana, Colorado, Utah, Nebraska, Missouri, Florida, Georgia, Tennessee, North Carolina, Ohio, Michigan New Hampshire, and parts of California, Minnesota, and Pennsylvania), a POLST Paradigm Program. However, in several states legislation enacted to create advance directives and DNR protocols may hinder the goal of national implementation. Hickman, et. al interviewed state emergency medical services (EMS) and long-term care (LTC) expert informants and conducted an independent legal review of each state’s (and the District of Columbia’s) law to “identify current state laws that could be potential barriers… (p. 120).”
Because the option to refuse nutrition and hydration can be particularly important for cryonics patients who wish to avoid the pathophysiology induced by a long agonal phase, it is important to note that:
Twenty-three states (45 percent) impose explicit limitations on substituted consent to forgo life-sustaining treatments via their advance directive or default surrogate laws. These limitations either focus on all life-sustaining interventions, including DNR and artificial nutrition and hydration, or only artificial nutrition and hydration.
Some states also require the patient to meet poorly-defined diagnostic preconditions such as “terminal condition,” “permanent unconsciousness,” and “end-stage condition” and/or additional medical certifications and witnessing requirements. DNR protocols in particular were found to frequently require such detailed specifications, medical preconditions, and witnessing requirements.
The POLST Program has significant potential in streamlining end-of-life treatment orders and providing maximum adherence to individual patient preferences. Such a program would be beneficial in assuring that cryonics patients receive appropriate treatment with the goal of reducing agonal pathology and ischemic injury to the brain prior to cryogenic long term care. The authors of the review recommend that:
States interested in developing a POLST Paradigm Program will need to review the compatibility of their existing laws with the POLST Program, and amend or adopt accordingly. States should strive to ensure the POLST form remains simple to use and maintains the goal of helping patients retain control over their end-of-life treatment.
A comprehensive list of potential statutory and legal barriers is provided in p. 126-139 of the report. A sample of the POLST Paradigm Form from Oregon may be found on p. 140. In addition, OHSU provides numerous resources and materials for developing a POLST Paradigm Program.