To POLST or Not to POLST

Edward Grant (attorney) and Lisa Anderson-Shaw (clinical ethicist) have addressed advance care planning, and specifically the POLST form (Physician Orders for Life-Sustaining Treatment) from their professional perspectives. Let me start my comments on their work by telling you about Earl.

A few years ago Earl, a healthy man in his 30s, made an appointment to talk with me when I was serving as Director of Clinical Ethics at a large teaching hospital. He was scheduled for a hernia repair in the near future and learned at his pre-admission discussion with a nurse that his advance directive (he had a Living Will) would not be recognized as a “Do Not Resuscitate” (DNR) order. He (rather angrily) wanted me to “set her straight,” but our time together turned into an educational session about advance care planning.

Grant nicely summarizes the history of advance care planning, its documentation, and both the assistance and barriers imposed on this endeavor by legislative attempts to clarify, formalize and make uniform the process. He identifies several differences between an advance directive and a POLST form, two of which are very important. Earl was not aware of either. (1) An advance directive is generated by a patient and is often focused on his or her wishes about limitation of treatment; a limitation of treatment order (including DNR) is written by a physician when the clinical situation is consistent with the patient’s wishes, and thus requires some interpretation. (2) An advance directive is about the future and does not take effect until the conditions outlined in the document come to pass; a DNR order is in effect as soon as it is written, no further interpretation needed. Many people, including many healthcare professionals, join Earl in not being aware of this second crucial difference.

Grant looks in detail at some of the statutory and regulatory problems with the increasingly popular POLST forms. In the end he concludes they are an improvement on previous advance care planning documents as long as we all recognize their built-in limitations and as long as their use is limited to situations of serious illness or frailty. He, correctly I believe, is critical of POLST forms for addressing not only resuscitation and intubation, but also artificially administered nutrition and hydration. I suspect this modality is included because of the many media cases and consequent judicial and legislative skirmishes that have generated so much controversy and disquiet. He is right, however, that decisions about the use or nonuse of fluids and nutrition is rarely an urgent matter. This is a matter better addressed in the patient’s advance directive rather than the automatically invoked POLST form.

Anderson-Shaw states that physicians have an obligation to discuss end-of-life care when they determine that a patient has a life-threatening illness. She later goes on to suggest that the opportune time to discuss advance directive preferences is when a person is healthy and not facing any emergent healthcare decisions. She also says that all persons over 18 should have a Durable Power of Attorney for Healthcare, thus designating the person they would trust to act as their proxy. I would expand these suggestions to place the onus on the primary physician. Since patients are often reluctant to bring up such matters, I believe the physician should take the initiative in this discussion while the patient is healthy, not just upon the diagnosis of a life-threatening illness. While the patient’s wishes may, in fact, change when such a diagnosis is reached, having a “dry run” at such a conversation during an annual health assessment can get the patient used to the idea that this is a legitimate and useful topic of conversation.

Anderson-Shaw includes the POLST form in her list of common advance directives, though she is careful to point out its differences from other directives, much as Grant has done. She supports their use, as do I, in situations of serious illness because of their uniformity and availability, different from other advance care planning documents.

In her role as a clinical ethicist, she goes beyond the utility of advance care planning and POLST forms in the general population to address questions and concerns often raised by Christians. She rightly points out that advance care planning is consistent with our acceptance of the finitude of earthly life, as well as with the biblical principles of sanctity of life and stewardship. She also sympathetically addresses situations in which believers request medically inappropriate treatments because they are “waiting for a miracle.” She underlines the palliative care perspective that when there is nothing more that can be done for a patient’s illness, there is still a lot that can be done for the patient and their loved ones. She concludes with a challenge to churches to expand their discussion from eternal destiny, as critically important as that is, to include informed discussion about how we die and how we can minister to each other during our final days on earth. I strongly support each of these points.

Edward Grant and Lisa Anderson-Shaw have together provided patients and families with important information and professional insights about the importance of advance care planning.