POLST Coming To Illinois

POLST Coming To Illinois

Posted on Tuesday, October 30th, 2012 at 10:22 pm by Life Matters Media

Oregon POLST

The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve the quality of end of life care, is on its way to implementation in Illinois. A task force made up of physicians, public health officials, chaplains and nurses is currently working to assemble and educate health care workers about the form.

POLST was developed in Oregon in the 1990s, and now 14 states have POLST programs. Twenty-eight states are considering the use of POLST forms.

POLSTs are more detailed than conventional living wills or advance directives. They allow patients to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across care settings and direct doctors to provide or withhold lifesaving treatment.

Julie Goldstein, M.D., a palliative care and clinical ethics specialist at Advocate Illinois Masonic Medical Center, leads the POLST Illinois task force and spoke with Life Matters Media.

“I work at the bedside. I see the results of people not having thought about their future,” Goldstein said. “Their loved ones have to make their decisions at a loss. I think with no directives from the patient, the default approach is maximum treatment, despite burdens and if treatments can help.”


The Illinois Department of Public Health is currently looking over the proposed form. “Individuals may be able to have the POLST form by the New Year, but we don’t know for sure yet,” Goldstein said.

The Chicago End-of-Life Care Coalition, a non-profit working with the task force, maintains that every person has the right to accept or decline medical treatment. This right is maintained, POLST advocates say, even if a patient loses the capacity to make medical decisions. POLST is just one advance care option.

The POLST form is always intended to travel with a patient, whether that is in an ambulance en route to a hospital, or in the instance a patient moves into a long-term care facility.

“The POLST form differs from a DNR form in that it addresses more life-sustaining treatment options than CPR and is recognized and honored by all institutions along the healthcare continuum in the states where it is utilized,” according to the CECC.

Unrealistic Expectations Among Terminally Ill

Posted on Sunday, October 28th, 2012 at 3:03 pm by Life Matters Media

Terminally ill patients often have unrealistic expectations of their treatments, write Thomas J. Smith, M.D. and Dan L. Longo, M.D. in an editorial for the October 25 issue of The New England Journal of Medicine. The physicians are advising their peers on how to facilitate open discussions with their patients about palliative care options and death.

The medical oncologists begin their editorial with a statement about the foolishness of self-deception, which they describe as a valuable personal coping tool. “It allows us to aspire to significance, strive for new knowledge, and yearn to make a lasting contribution to the world despite the certainty of our inevitable end. Indeed, no arduous task would ever be undertaken if we were unable to exaggerate the benefits we expect from it and underestimate the difficulty of its accomplishment.”

To them, this “planning fallacy” is a symptom of human nature. The need to hope, they write, leads to unnecessary and expensive care at end of life.

This “self-deception” is illustrated in a study also published in the Journal by Dana-Farber Cancer Institute’s Jane C. Weeks, M.D. and colleagues: “Patients’ expectations about effects of chemotherapy for advanced cancer.” Twelve hundred patients with metastatic lung cancer or colorectal cancer were asked whether they expected their treatment to cure them. According to the study, the majority of patients felt their treatment would do so.

“If patients actually have unrealistic expectations of a cure … administered with palliative intent, we have a serious problem of miscommunication that we need to address,” Smith and Longo write.

Four possibilities could have resulted in unrealistic hope for some of the 1200 patients, the authors assert: 1) the patients surveyed may not have been told that their disease was incurable, 2) they were not told effectively, 3) they chose not to believe the message ,or 4) they responded too optimistically to the questions asked.

They share some surprising facts. Two thirds of doctors tell patients during an initial visit that they have an incurable disease, and only about a third actually state the true prognosis. On top of that, about one third of patients refuse to admit that treatment will not cure them.

The authors offer suggestions for improving communication between patients and physicians about terminal diagnoses. They suggest that oncologists provide more personalized information to patients. “Nearly all patients want to know whether or not they can be cured, and the majority want to know their prognosis.”

One tactic is “ask, tell, ask,” a method asking patients what they want to know, telling them and then asking if they understand. This should be done in a series of conversations.

“This ‘best practices’ model has allowed one large provider to double patients’ length of participation in hospice programs,” they write. This is important because palliative care increases knowledge of the prognosis and helps make patients more comfortable by reducing stress and pain.

Better communication also helps to reduce total costs of care. The authors note that 25 percent of all Medicare funds are spent in the last year of life. Life Matters Media has previously reported that a quarter of Medicare recipients spend more than the total value of their assets on end of life care.

At a recent forum at Northwestern University’s Buehler Center on Aging, Health and Society, George D. Lundberg, M.D. said that palliative care is the right option for some 80 percent of patients who die of chronic progressive disease. However, most of these patients die in intensive care units, and often against their will.

Medical Marijuana: DEA Classifies Cannabis Alongside Heroin And LSD

Posted on Wednesday, October 24th, 2012 at 10:35 am by Life Matters Media

A patient and physician-based organization supporting the legalization of medical marijuana asked a federal appeals court last week to ease regulations on the drug. The organization, Americans for Safe Access, also accused the federal Drug Enforcement Agency of acting arbitrarily in refusing to reclassify marijuana as a less harmful drug. The federal government currently lists marijuana as a Schedule I controlled substance, meaning it has no medically accepted use and high potential for abuse.

A three-judge panel heard Americans for Safe Access v. Drug Enforcement Administration for the U.S. Court of Appeals for the D.C. Circuit. The last time the appeals court considered marijuana’s classification was in 2002.

The Huffington Post reports that Americans for Safe Access lawyer Joseph Elford asked the court to force the DEA to reconsider its classification of cannabis as a Schedule 1 drug. Other drugs classified as Schedule 1 include heroin and LSD. Drugs like cocaine, opium and methamphetamine are classified less strictly, as Schedule II, indicating “some accepted medical use.”

Elford also accused the DEA of ignoring 200 well-controlled studies that demonstrate that cannabis has legitimate medical uses. The Chicago Tribune reports that Americans for Safe Access wants the court to reclassify marijuana a Schedule III, or lower, drug.

Government lawyer Lena Watkins told the court, “They don’t have the type of study that would allow them or any other expert to reach a conclusion about the medical utility of marijuana.” She said the DEA found no “substantial evidence” of acceptable medical marijuana use.

She maintained that marijuana is dangerous, saying it causes “adverse physical and psychological consequences.”

The DEA rejected the studies Elford cited, Watkins said, because they did not meet the standard of double-blind FDA approval trials. She said results are still pending from 15 government-approved studies.

“This game of ‘gotcha’ will continue indefinitely unless this court intervenes,” Elford told the panel. “They won’t allow additional research to be conducted.”

The crux of the case rests on disabled military veteran Michael Krawitz. According to Americans for Safe Access, Krawitz was denied access to Veterans Administration services because of his use of marijuana for pain and stress. Krawitz resides in Virginia, where marijuana for medical use is not approved.

The official blog for the Americans for Safe Access reports that the court has ordered supplemental briefing on the issue of “standing,” which the organization describes as a rare move.

“[The] order asks the petitioners to provide the court with details about how plaintiff Michael Krawitz, a U.S. Air Force veteran, sustained harm as a result of the federal government’s refusal to recognize the therapeutic value of marijuana,” according to the posting.

The Los Angeles Times’ David G. Savage reports: “Marijuana’s classification as a Schedule I drug dates to 1970, when Congress passed the Controlled Substances Act. On two occasions since then, marijuana advocates have petitioned the DEA to reconsider the classification, citing the medical benefits of cannabis.”

Medical marijuana supporters have already won local approval for medical use in 16 states and D.C.

POLST Excluded From Wis. End Of Life Care Program

Posted on Sunday, October 21st, 2012 at 8:00 pm by Life Matters Media

A form directing physicians to withhold or continue lifesaving treatment for terminally ill patients is missing from statewide pilot program Honoring Choices Wisconsin, designed to educate more people about end of life care. The controversial Physician Orders for Life-Sustaining Treatment (POLST) is excluded because critics, including Catholic bishops, say the form lays a foundation for euthanasia and abuse, while proponents consider the POLST an advocate for terminal patients’ rights.

“POLST is a physician order that does not need the patient’s own writing,” explains Katharine Karage, Advance Directives Coordinator at Mayo Health System in La Crosse, Wisconsin. “POLST is four questions where the physician identifies with their patient what areas of care you want depending on what your illness is.”

POLSTs are more detailed than conventional living wills or advance directives. They allow patients to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across care settings and direct doctors to provide or withhold lifesaving treatment.

Tim Bartholow, chief medical officer of the Wisconsin Medical Society, chose not to include POLST as part of the statewide pilot. “POLST is the lightning rod at the moment,” he told the Journal Sentinel. “I think we’ll get there, but it could be three or four years before there’s consensus about this.”

POLST aims to ensure patient wishes are executed in hospitals and unexpected medical situations. POLSTs were first developed in Oregon during the 1990s.

A sample POLST obtained by the Journal states: “Any section not completed indicates full treatment for that section. When need occurs, first follow these orders. Then contact physician.”

“Families were saying, ‘Why can’t we talk to each other?’ and ‘If we write orders in one place, why are they ignored in another?” says Margaret Murphy Carley, executive director of the National POLST Paradigm Task Force at the Oregon Health and Science University. “So you have an advanced directive. Where is it? In a drawer? In a safety deposit box? That’s the problem.”

Stephen Pavela, an internist with the Mayo Clinic Health System-Franciscan Healthcare in La Crosse, opposes statewide implementation, though Mayo has used POLSTs since 1997. “POLSTs lock into place orders that in the moment might not be appropriate and might be dangerous,” he told the Journal.

Wisconsin’s Roman Catholic Bishops issued a warning against the use of POLST. “A POLST form presents options for treatments as if they were morally neutral,” the bishops wrote in a letter published by the Wisconsin Catholic Conference. “In fact they are not.”

The letter continues: “A POLST oversimplifies these decisions and bears the real risk that an indication may be made on it to withhold a treatment that, in particular circumstances, might be an act of euthanasia.”

Bud Hammes, who leads the Respecting Choices program at Gundersen Lutheran Hospital, says that opponents aren’t understanding the many issues that arise in end of life care. “I work shoulder to shoulder with doctors and nurses who care every day for dying patients. They see the pain. They see the suffering when there is not good planning.” The Respecting Choices program will train participating health systems and organizations to properly use POLST.

“What makes this program tick is the redesigning of health systems so that it becomes part of routine care. We need to make sure it’s not an afterthought, and not something the patient does on their own,” Hammes says.

The Journal reports that fifteen states have endorsed POLSTs with legislation or administrative rules protecting providers who sign and follow them from legal liability. Some 20 others are developing POLST programs.

Read more about Honoring Choices Wisconsin here

Read the bishops’ letter here

Doctors Must Monitor Health Costs: One Physician’s Plea To His Peers

Posted on Thursday, October 18th, 2012 at 9:13 pm by Life Matters Media

George D. Lundberg, M.D.

Physicians have both the duty and unique power to improve end of life care in the U.S., said George D. Lundberg, M.D., speaker at the James E. and Bonnie L. Eckenhoff Lecture at Northwestern University’s Buehler Center on Aging, Health and Society.

The U.S. spent around $2.7 trillion on health care costs last year, yet the quality life for Americans has not improved or translated into better care, said Lundberg, the editor-in-chief of CollabRx, a genomic-based health care analytics company. Lundberg acknowledged that many see health care spending as exorbitant for what consumers get in return. But actually, he said, consumers receive a lot- testing, technology, medication, surgery and hospitalization- whether or not all such things are really necessary. “Often a lot of what we need we only get a little. That, in a nutshell, is the problem.”

Health care reform is needed 

Lundberg asked the audience of medical students, doctors and nurses who controls American health care. “No one and everyone,” he answered. “Anarchy and chaos stand side by side. There’s nothing remotely akin to a U.S. health care czar. The marketplace determines how much money is spent on what, and how many people of what types work in health care. It is by no means a free market.”

He also asserted that lobbyists for hospitals, physicians, insurance companies and pharmaceutical companies exert tremendous power over U.S. health care, and as a result, they also control the U.S. economy. Health care spending amounts to 18 percent of the nation’s entire expenditures.

I want you to know and I want you to care about what you prescribe is going to cost. Insist, rise up as one, demand to know.

Lundberg said the U.S. health care system is the best in the world, for those who match the following ten-part description: 1)  having full health insurance that can’t be taken away 2) living in  a major metropolitan area 3) having a long term relationship with a physician 4) having knowledge of English and lacking a hearing or visual impairment  5) having education 6) having financial resources and access to transportation 7) being white 8) being naturally skeptical 9) having internet access 10) being male. Lundberg said most politicians who champion U.S. health care fit the prior description. “How about all the rest?”

Some simple solutions to health care

Monitoring spending is the simplest way to cut health care costs, Lindberg argued, and he made a personal plea to physicians to help with the task: “I want you to know and I want you to care about what you prescribe is going to cost. Insist, rise up as one, demand to know.” He noted that greater transparency of costs would also help lower spending.

Lindberg said that physicians have a duty to change individual care as a group or individually, because they are in charge of treatments and interact with patients. “They make the real things happen.”

End of life care

Lundberg concluded with a focus on end of life care. “Death is not the enemy. We all die,” he said. “The enemies of patients aren’t physicians. Disease, disability and pain, those are the enemies. I believe that all people deserve a death with dignity and without pain.”

Palliative care is the right option, he said, for some 80 percent of patients who die of chronic progressive disease. Unfortunately, most of these patients die in intensive care units, and often against their will.

Hospice care is also right for many, Lundberg said, but the process of the patient and family choosing the option often takes too long to receive its full benefit. “The main key to getting it right for patients with incurable chronic progressive disease is counseling. Medicare could pay for it.”

Lundberg is an academic pathologist and has 30 years of editorial experience writing and editing for major peer-reviewed medical journals, including: the Journal of the American Medical Association, 10 AMA specialty journals, the Medscape Journal and e-Medicine from Web MD.