The Pennsylvania Senate Health and Human Services Committee voted unanimously to advance Senate Bill 623 on December 12, 2017, kicking off the legislative process. There are many more steps before it could become law. The measure would codify the use of Pennsylvania Orders for Life Sustaining Treatment (POLST) and is designed to clarify provisions regarding Do Not Resuscitate (DNR) orders.
POLST forms have been used in Pennsylvania for years without official legislative authorization. The Pennsylvania Catholic Conference (PCC) and the Pennsylvania Catholic Health Association (PCHA) have been part of a group of stakeholders working to get statutory controls to govern their use.
Fundamentally, SB 623 would bring necessary regulation to POLST; but as proposed, the bill does not go far enough to safeguard human life. PCC and PCHA are asking for amendments that would assure that these documents are only used in appropriate situations. The law should guarantee that a POLST would be used solely for patients with a qualifying health status, diagnosis and prognosis where their doctor would “not be surprised if they died within the next year.”
Amending the bill to clarify that POLST applies just to patients determined to be in the end stages of life would put important protections into the law. With the current practice, many facilities ask all patients admitted to a hospital, a long term nursing home, or other health care facility to sign a POLST, even without consulting a doctor. There has also been an increase in POLST use in healthy patients presenting to primary care physicians for their annual wellness visit. Patients and their families should pay attention to what they are signing and why. Anyone can and should sign a living will; but most patients should not qualify for POLST.
POLST and end-of-life decision making is complex. The PCC and PCHA consulted with Dr. Ferdinando Mirarchi, Principal Investigator of the TRIAD research series and Chief Medical & Scientific Officer of the Institute on HealthCare Directives and the Founder of MIDEOTM (My Informed Decision on VidEO) to learn more. Here is a summary of his answers.
What is POLST?
The term POLST stands for the Physician Orders for Life-Sustaining Treatment or locally, Pennsylvania Orders for Life-Sustaining Treatment. In other states the form might have a different name such as MOLST or Medical Orders for Life-Sustaining Treatment.
POLST is meant to serve as a portable, standing medical order that specifies whether life-sustaining treatment is to be used or withheld for a specific patient in various circumstances.
Who uses a POLST and when?
By its true definition, POLST is not for healthy people or even those with chronic conditions. It is only appropriate for those with terminal illness who are expected to die within a year.
NOTE: PCC and PCHA have concerns because Senate Bill 623 has no such limitation. As written, there are no safeguards to prevent an uninformed young person, or the most at risk, a healthy older person from having a POLST.
Who decides if a POLST is appropriate?
When used properly, a physician in consultation with the patient or designated representative should determine when it is appropriate to have a POLST. Based on moral and ethical principles POLST is only appropriate if there is a diagnosis of advanced chronic, life limiting, or terminal illness. And it is only appropriate if the physician and the patient and/or the family or other representative have first had an in depth conversation about what POLST means. To date, both medical practice and research has shown that physician involvement and in depth conversations have been lacking or absent.
NOTE: Senate Bill 623, nor the companion bill, House Bill 1196, do not require a diagnosis nor impose any condition for appropriateness of POLST. The bills do not require a conversation with a physician or even the review of the patient’s medical records by the signing medical professional.
How is POLST different from a living will or a do-not-resuscitate order?
A POLST is an immediately actionable medical order that is different from a living will. It may or may not contain a Do Not Resuscitate (DNR) order depending on how it is completed.
The orders outlined in this medical document are supposed to be followed by paramedics, nurses, and other physicians even though they may not have been involved in the creation of the initial medical orders.
The POLST form itself is to be honored in a facility such as the hospital and is transportable so it will also be honored in the post-hospital settings such as skilled nursing facilities or in the pre-hospital ambulance settings.
A living will is different from a POLST. A living will is a legal document outlining a patient’s treatment preferences which can be honored when the patient cannot speak for him or herself.
A living will gives instructions and preferences, but should not obligate medical professionals to follow them. Consider how a typical last will and testament for your property is used. Simply creating a will for your estate does not give your family the ability to take your assets. The will has to be triggered and that trigger is your death. At the time of your death, and only then, can the assets be divided up according to the instructions contained in your will. A living will is triggered when your health status prompts questions about your medical treatment. The triggering events are when you are not able to consent for yourself and you have an end stage medical condition or have entered a persistent vegetative state.
A DNR (Do Not Resuscitate) order (inside or outside a hospital setting) is different from a living will and may or may not be contained in a POLST. In Pennsylvania, a DNR order is a medical order that pertains to one specific condition, cardiac arrest. So if a patient agreed to a DNR order, then he or she wishes not to receive CPR in the event of cardiac arrest.
A significant patient safety risk is posed when patients are asked the question of DNR. We know from years of research that patients with DNR orders are at risk to receive less than the expected medical care when not in a cardiac arrest situation. We aggressively try to remind health care providers and patients families that a DNR order is not the same as a do not treat order.
Also, a standard living will and POLST are often misinterpreted as DNR orders regardless of what is documented in those forms.
A Patient to Clinician Video is another form of advance directive that is used increasingly. This new technology allows you to do this on your own or through a trained physician. However, be careful to understand that an un-scripted video can pose just as significant a patient safety risk as a vague living will or POLST. There are definite benefits of video if it is “scripted.” This is to ensure your wishes are not misunderstood by medical providers in your own community or when traveling. There are a multitude of companies that have deployed video directives and an increasing number of other programs in development. As such, if approached to consider this in the physician’s office or prompted via a “Do It Yourself” (DIY) app, consider seeking advice from a physician experienced in this field of medicine and be sure he or she is an expert in Patient Safety & Advance Care Planning.
What questions about POLST should people discuss with their doctor or other health care practitioner?
Unless you have an advanced chronic, life limiting, or terminal illness, your physician should not even be asking you about POLST; however discussing an advance directive such as a living will is appropriate.
See Living Will and Health Care Power of Attorney: What you should know about ADVANCE HEALTH CARE DIRECTIVES from the Bishops of Pennsylvania
If you are of advanced age and your doctor has advised you that you are high risk to die within the current year, then your spouse, children or whomever you have appointed as your health care agent should talk to your doctor. Decide together:
- How those who are treating you are going to be aware that you have created a POLST?
- Will those treating you safely understand your choices if you use a POLST?
- How will you be treated if you experience a sudden cardiac arrest?
- How do you wish to be treated when not in cardiac arrest?
- Will this POLST potentially place you at risk when not in cardiac arrest?
Am I required to have one? What if I refuse?
By law, no one is required to have a POLST form. It is to be a voluntary process. If you refuse a have a form completed and you feel pressured to complete a POLST form, you should ask to speak to the administration of that facility. Be careful of what you sign when you enter a healthcare facility. Many patients who have a POLST created are not aware that it is being created for them. Also, if the facility is not honoring your concerns, then you should report the situation to the Department of Health. Call 1-800-254-5164 and visit www.health.pa.gov to download a complaint form.
End-of-life decision making can be confusing from a secular and medical standpoint, but you may also wonder: what does the Catholic Church teach about POLST and end-of-life decision making?
As Catholics, we believe that we have a responsibility to preserve our life. Suicide and/or assisted suicide are always morally wrong. (Declaration on Euthanasia: Congregation for the Doctrine of the Faith, 1980)
However, we also believe there are some limited qualifications to the obligation to attempt to preserve life, such as the refusal of overzealous treatment, including medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome. (Catechism of the Catholic Church, #2278, 1995) It is morally permissible to sign a POLST if it follows the documented indications for use, and if it is determined that medical treatments would not offer reasonable hope of benefit or are disproportionately burdensome. “Disproportionately burdensome” means the treatments will impose serious risks or excessive pain to the patient, excessive expense on the family or the community, or other extreme burdens.
Death is not to be feared as the end of our existence, rather it is the doorway to our eternal destiny.
A decision to forego a medical treatment should not be made because a person’s life is judged as not meaningful. If you are approached to sign a POLST document, you should not feel compelled to sign it immediately. You should discuss your health status with your family and your doctors and then decide if POLST is appropriate for you to complete. To simply complete such documents without knowledge of how they impact your care and treatment is a significant safety risk to you as well as to your family. The most important step in creating a POLST is having a conversation with your medical provider. Make sure your choices are informed and created appropriately for you as an individual. Take care to outline your end-of-life wishes safely and right.