This week, the LA Times published an op-ed opposing POLST. The writer, Ben Mattlin, concedes that "the attention being given to end-of-life choices is a good sign for those of us who are concerned about patients' rights." He also concedes that "too many people die in hospitals rather than at home where they'd prefer to be."But Mattlin also argues that "there's no provision to ensure how well informed you are at the time to make such a decision. . . . POLST merely hastens uninformed decision-making based on fear."
Mattlin is correct that a patient (or surrogate on behalf of an incapacitated patient) might complete a POLST without fully understanding or appreciating the prognosis or alternatives. Clinicians might even pressure the patient/surrogate to complete the POLST in a certain way.
But those concerns hardly make for a case against POLST.
- First, it is an optional an voluntary tool. If you do not want to complete it, then do not complete it.
- Second, you can complete a POLST in any manner that you want. If you want to opt for all life-sustaining measures, then do so.
- Third, the risks of under-informed decisions are not unique to POLST.
- Fourth, POLST is for incapacitated patients. if the patient still has capacity, then she can make her own treatment decisions.
As Mattlin observes, POLST has been proven to have significant benefits in terms of assuring that patients get o more and no less than the treatment they want. Mattlin and other opponents have not provided persuasive evidence demonstrating that these benefits are outweighed by risks.
In California's legislature there is currently a bill to authorize placing organ donor on a driver's license which, as you say, is a choice. However, the bill is an opt-out type authorization meaning that it is presumed that the driver is an organ donor unless the license states otherwise. That's not choice.
ReplyDeleteIf the misuse of DNR Hospital Code status to hasten death for fiscal expediency was disclosed to Medicare/Medicaid patients, the public would understand the "danger" of the advanced directive to include the POLST.
ReplyDeleteThe manipulation of hospital code status that removes the autonomy of the patient is against the law, but the law is being circumvented and ignored in the interests of fiscal expediency for the hospitals.
Doesn't your paper on the treatment of "Involuntary Passive Euthanasia in the US Courts" raise the red flag?
Thad: I have great respect for your views and research in bioethics but I am disappointed in your rather lackluster defense of POLST here.
ReplyDelete(Pope) It is an optional an voluntary tool. If you do not want to complete it, then do not complete it.
Problem is, POLST is increasingly being promulgating as a mandatory COA document at many skilled nursing facilities. And quite often, there is no clinician involved in the discussions. This is antithetical to a a document that was designed to be voluntarily completed with one's physician.
(Pope) You can complete a POLST in any manner that you want. If you want to opt for all life-sustaining measures, then do so.
You know better than most people that such 'advance request' documents are far less legally and clinically binding. Worse still, since POLST was originally designed to be completed by folks with a life expectancy of 12 months or less, opting for all life-sustaining measures is counter-intuitive and potentially hazardous. What physician in her right mind would advise such a blanket set of responses?
(Pope) The risks of under-informed decisions are not unique to POLST.
Fair enough, but POLST was specifically designed as an improvement over vague, patient-completed medical directives.
(Pope) POLST is for incapacitated patients. if the patient still has capacity, then she can make her own treatment decisions.
But most patients don't retain capacity toward the ends of their lives. Ergo, a poorly considered POLST form can result in decision-making that may not be in keeping with the patient's wishes or best interests.
(Pope) Mattlin is correct that a patient (or surrogate on behalf of an incapacitated patient) might complete a POLST without fully understanding or appreciating the prognosis or alternatives. Clinicians might even pressure the patient/surrogate to complete the POLST in a certain way. But those concerns hardly make for a case against POLST.
But those are not casual concerns, either, and they do support (IMO) a case for some measured POLST reforms.
I remain a ardent supporter of advance directives and advance care planning. And I know that POLST works very well in some places and that its deficiencies can be readily addressed. However, as someone on the proverbial front lines who deals with these documents on very regular basis, I find myself agreeing with a lot of what Mattlin and Jason Manne have written on the topic. I don't have a political or ideological dog in this fight - I simply want POLST to work as advertised.
RH - 2 quick responses
ReplyDelete1. I am not sure how to reconcile your first two points. They seem inconsistent and in contradiction.
2. Can you provide or describe a specific case or type of case in which POLST was not implemented "as advertised"?
I am not seeing the inconsistency(?)
ReplyDeleteThe practice of mandating a POLST for all nursing home residents effectively nullifies its voluntariness and may encourage an careless, rote completion and violates the spirit of PSDA.
I have spoken to two SNF administrators who told me that the reason they require POLST (POST, in my state) for all their residents is so that they will have everyone's code status in advance and thus know when to call 911. These POST forms are COA documents and a social worker is available to answer questions. A facility physician signs them later but has no real-time involvement in their completion.
I have encountered many POLST forms completed by unauthorized agents (not the MPOA, legal guardian, or surrogate). I have also seen POST forms ostensibly completed/signed by principals who clearly had advance dementia by the date on the form and could not have possibly known what they were signing.
POLST was originally 'advertised' as being appropriate for seriously ill individuals who have a significant chance of dying with 12 months. (Otherwise, a standard Living Will should easily suffice.) Moving those goalposts back and requiring completion will continue to fuel some of the 'underlying agenda' concerns from religious, disability rights, and other groups. The actual POLST agenda is innocent and noble: to encourage more folks to engage in meaningful advance care planning. But wherever accomplishing that goal involves required completion and obviates any meaningful physician involvement in the process, then I think it is inviting such attacks.
Again, these are admittedly anecdotal incidents and my own subjective opinions and not reasons to throw out the baby with the bath water. Taken collectively, however, they do indicate (to me) sufficient need to tighten up the process.
I'm a practicing geriatrician and I agree that many of RH's concerns are legit.
ReplyDeleteI wrote a blog post for family caregivers about POLST, and I warned them that some facilities, or even primary care doctors, do give families POLST with no support in completing. A site visitor promptly posted a comment to that effect.
I've also had a few patients who've had POLST completed by palliative care in the hospital saying "Comfort Measures Only" but then the patient recovered substantially and that directive was no longer a good fit. Needless to say, most outpatient medical clinics are not prepared to help a family revise POLST, and most people cannot access an outpatient geriatrician or palliative care doctor to help them with this.
I do think we are overall better off with POLST than without, and some reforms/adjustments will probably help.
thanks for this post & comment thread, very interesting.