Tuesday, November 27, 2012

POLST - DNAR without Consent

I strongly support POLST.  I have been actively engaged with its implementation in both Delaware and Minnesota.  And I am presently preparing a lengthy report to aid the continuing nationwide roll-out.  

But I was surprised to see that some POLST programs and forms explicitly permit unilateral clinician orders.  This form from Vermont, for example, permits the clinician to complete a DNAR order on a patient's POLST without either patient or surrogate consent, in the case of "futility."  
I am not saying that I am necessarily opposed to this development.  Many states have taken the opportunity, when introducing new statutes and regulations authorizing POLST, to fix some other limitations and problems in health care decisions law.  I was simply surprised, because so much of the defense of POLST, in response to attacks from certain Catholic officials, focuses so heavily on its voluntary nature.          

4 comments:

  1. I had not heard of this, either. Thanks for bringing this to our collective attention. What other states beside Vermont include this?

    I think a unilateral futility clause in POLST is a patently bad idea because it obviates the informed consent relationship and the due process approach to medical futility. Further, it could undermine the entire POLST/POST/MOLST paradigm.

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  2. POLST laws typically fit "inside" existing state healthcare decisions laws. Here, the POLST legislation presented an opportunity for a substantive amendment. I will need to look more carefully at all the other new statutes and regulations to see what else has "snuck" in.

    I have a trip to Vermont planned, and hope to learn more about why/how this was added.

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  3. I agree. The unilateral DNR is in violation of existing law because even when futility decisions are made, the families are informed as to any rights that they may have in the interests of their "due process" rights, as in the Texas law. .

    As a victim of a covert/ unilateral DNR that was placed in my husband's hospital chart for the financial/personal epediency of the physician and the hospital, this is a very traumatic and hurtful experience to live through.

    Obviously, physicians should be mandated to SEEK informed consent for palliative care as opposed to curative care from elderly Medicare/Medicaid patients with terminal diseases. This would stop much of the overtreatement and waste ---but, of course, it would negatively impact profits.

    Obviously, there is much dishonesty and lack of transparency about the connection of "overtreatment" of the elderly and the public policy of the option of palliative care and hospice arrangements at the end of life---which are INTENDED to reduce the high costs of dying of the growing elderly population by keeping them out of expensive ICUs and CCUs and encouraging them to die more comfortably and less expensively in other settings.

    The DNR Code Status is already being misused as hospitals try to defend against lack of reimbursement because of non-beneficial "overtreatment" by physicians/hospitals that is NOT being reimbursed by CMS and the private insurers who contract with the government to provide Medicare benefits under private policies.

    Who REALLY is looking out for the old people? If unilateral DNRs are legalized, they will be used by hospitals against the elderly as a financial tool to "manage" and "cap" unreimbursed costs.

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  4. In an Article, published on line in February of 2011, by the Journal of Internal Medicine, entitled "Hospital Do-Not-Resuscitate Orders: Why They Have Failed, the authors warn that "Health Care Professionals inappropriately etrapolate DNR orders to other treatment decisions -------and further they say "While these providers may believe their decisions are made in the patient's best interest, their judgment is subjected to personal biases and their asumptions can be faulty."

    Personal biases might certainly be the result of non-reimbursed costs of treatment because of non-beneficial OVERTREATMENT, ERRORS and OMISSIONS, and because the patient has exceeded the Diagnosis Related Group Cap.

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