A New Type of Advance Directive
Most of you remember the original “Living Will” that people were to sign stating their desired medical treatment and care. Very simple but potentially deadly. Now there is a new form Physician Orders for Life-Sustaining Treatment (POLST also called MOST or MOLST) It is only one page but just as deadly if not more so.
The main difference from the Living Will is that a signature of a physician (or nurse practitioner or physician assistant) is part of the form making the POLST form an actionable medical order – meaning restrictions apply the instant the order is signed.
Background
The POLST document was started in Oregon, the state that first made physician-assisted suicide legal. At this time it has spread to eleven states and it is pending in at least eighteen others. There are seven ethical and dangerous problems with
POLST:
No Real Safeguards
- No patient signature is required for POLST implementation. In at least three states a patient’s signature is optional while the doctor’s signature is mandatory.
- It can be implemented when the patient is not terminally ill. POLST annuls the Living Will’s requirement that two physicians confirm that a patient is terminally ill or in permanent unconsciousness. This decision is strickly up to the patient which opens the door to suicide and euthanasia.
- No signature is required of the primary care physician when the orders are implemented. Any ER doctor, nurse practitioner, or physician assistant can sign the Do Not Resusitate (DNR) order.
- The orders travel with patients from one health care facility to another. Once this is signed it goes with the patient – this could be helpful if the document is regularly updated but there is no such requirement so again any ER doctor, nurse practitioner, or physician assistant can carry out the instructions without knowing the primary care physician or the patient. POLST even states: “FIRST follow these orders, THEN contact physician.”
- The orders are effective immediately. The patient doesn’t have to be terminally ill. The health care providers are protected from civil, criminal or disciplinary actions. Family wishes can be ignored.
- “Facilitated” by Non-physicians POLST documents are routinely initiated by others such as nursing home administrators, who interview patients, record the results and send the completed POLST document for a physician’s signature. No witnesses are necessary. These facilitators take a two-three day course which may teach that the removal of food and water is not painful. The patient doesn’t have the protective care of their primary care physician who knows them. If they suffer dementia, they are easily led to make bad decisions.
- POLST is based on a simplistic checklist of orders which exacerbate already existing problems with living wills by utilizing the simplistic check-box format. Good advance directives take into account what might develop in the future concerning the healthcare of an individual.
Conclusion:
To quote the January 2012 Volume 37, number 1, Ethics and Medics, National Catholic Bioethics Center, “Clearly there are unique, identifiable problems with the basic concept an implementaiton of the POLST model. From the perspective of good medical prcedure, POLST, similar to a poorly written advance diretive, is flawed because it disallows appropriate reflection based on actual events, that is, ‘in the moment medical decision making’ and so binds the hands of doctors even when they have grounds for questioning its utility. Given this reality, the basis for advocacy of these documents should be seriously questioned.” Written by three MDs and one PhD.
What can we do?
Make sure your local hospital doesn’t accept POLST forms or at least modifies them to be consistent with good health care practice and the full dignity of the human person. Make sure your local hospital accepts other advance directives. Be aware that under the Obama health care plan, Medicare and Medicaid benefits might be tied to the completion of a POLST document. And most importantly keep a close watch on what your loved ones sign. Even if you are the designated decision maker you may be left out of the picture.