For many seriously ill and aged Americans, advance health care directives alone will not be enough to ensure their end of life care preferences are honored in case of emergency or incapacity, said Oregon Health and Science University medicine professor Dr. Susan Tolle during a lecture Wednesday at the University of Chicago MacLean Center for Clinical Medical Ethics.
Tolle, the director of the OHSU Center for Ethics in Health Care, began developing and disseminating the Physicians Orders For Life-Sustaining Treatment (POLST) program in 1991. POLST is a medical order that allows the terminally ill to make clear what medical treatments they desire and wish to avoid; they may indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. They may also indicate the location where they prefer to receive care.
POLST, first adopted in Oregon, is far more detailed than conventional living wills or advance directives. The form must be signed by a medical practitioner to be valid.
Tolle’s hope is that patients in their last year of life will carry a copy with them to guide emergency medical services to provide or withhold specific treatments. Ideally, a POLST form will be completed only after meaningful conversation among the patient, doctor and family.
“There has been general agreement for at least 20 years that people have a right to make decisions about the treatments they want at the end of life,” Tolle said, emphasizing that traditional advance directives are still valuable in lifting emotional burdens from family members deciding among end of life treatments for loved ones.
“It is emotionally less demanding for family members who stand by what they’ve been told to do,” Tolle added. “Advance directives also allow you to appoint a surrogate. They do some really important things.”
However, Tolle argued that advance care plans are more “philosophical and for the future.” As seriously ill individuals approach death, she said those plans should become “for tonight” in the form of a medical order.
Increased rates of advance directive completion have had little effect on the location of death; while only 10 percent of elderly Americans say they wish to die in a hospital, more than 40 percent do.
Tolle led a recent study of death records from 58,000 people who died of natural causes in 2010 and 2011 and determined some 30 percent had copies of their POLST form in a state-wide registry. Researchers compared the location of death on death records to POLST patient preferences, Reuters Health reports.
POLST includes three order sets that could impact the location of medical care. More than two-thirds of patients with POLST forms had chosen the first option: “prefers no transfer to hospital for life-sustaining treatments . . . transfer if comfort needs cannot be met in current location.”
In 2013, Illinois modified the Department of Public Health Uniform DNR Advance Directive to closer resemble the National POLST Paradigm standard. More than a dozen other U.S. states have similar programs.
Dr. Susan Tolle will receive the 2014 MacLean Center Prize in Clinical Ethics, an award of $50,000, during the Dorothy MacLean Fellows Conference on ethics in medicine. The conference will be held at the University of Chicago Law School on Friday and Saturday, Nov. 14th and 15th. The MacLean Center Prize is the largest award in the field of clinical medical ethics.