Unbiased Solicitation of Patient Needs and Wishes
Max Diamond, M.D., Mary-Kate Kelledy, J.D., Kendra Oliver, MBA
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Situation
The questions on the POLST form empower patients with the ability to declare the scope of treatment they wish to receive during end-of-life care. Given the value of the aftereffect of these questions, they must be asked in a manner which is not only clear and empathetic, but also one that ultimately reminds the patients 1) that they are encouraged to discuss their concerns, and 2) that their wishes will ultimately be met.
Assessment
The purpose of the POLST Form is to facilitate communication between health care providers and their patients (or Legally Recognized Decision-Maker) regarding their personal end-of-life wishes and to also translate those wishes into clear medical orders. The POLST Form is written in a format to expedite review during an emergency situation. However, even though the form is designed to efficiently elicit information, the urgency of the situation should not dictate sacrificing a thorough collaboration between the physician and the patient. In other words, the importance of the questions being asked cannot be lost in the urgency in which they are presented. Hence, we recommend caregivers do advance planning with the patient and their families employing the POLST form.
The questions on the form are divided into four different categories, boxes A through D. For example, Box A elicits the patient’s wishes relating to Cardiopulmonary Resuscitation (CPR). The box details the possible scenario where the patient “has no pulse and is not breathing” and then directs the patient to choose what course of action they would prefer: Attempted Resuscitation (CPR) or Do Not Attempt Resuscitation (DNR) to Allow Natural Death (AND). While mechanically the decision is as easy as simply “checking” one of the boxes, the discussion needed to clarify the significance of each of the choices is quite complicated. Specifically, the medical provider should confirm that the patient understands what the word “resuscitation” means, what happens when resuscitation is not administered, and how that relates specifically to that patient’s personal condition.
The discussion can become even more complicated in scenarios where the provider, either personally or professionally, may disagree with the patient’s own choice. For instance, a physician may suspect that an elderly patient’s quality of life following a successful resuscitation would be difficult, and therefore diminished. However, the physician while imparting their professional knowledge, must try to not impart their own personal beliefs or bias on the patient. It is important to remember that quality of life is not an objective standard, but it is rather measured subjectively from person to person, patient to patient. The compassion behind the POLST form is that it empowers otherwise helpless patients to define the parameters of their quality of life and expectations moving forward.
As discussed in the first article in this series, “How to Start the Conversation,” the POLST Form is best discussed bottom-to-top, reading from Box D up through Box A, rather than from top-to-bottom.
Another article of this series on POLST will explore “A Medical Professional’s Reflection.”
References
1. POLST Education. Retrieved October 2018 from https://familydocs.org/eol/education/polst
2. California POLST Form. Retrieved September 2018, from https://capolst.org/wp-content/uploads/2017/09/POLST_2017_Final.pdf
3. The Physician Orders For Life-Sustaining Treatment (POLST) Coming Soon To A Health Care Community Near You, Robert B. Wolf, Marilyn J. Maag, and Keith Bradoc Gallant, Retrieved October 2018 from http://www.polst.org/wpcontent/uploads/2014/11/WolfMaagGallantVol49No1.pdf
4. The Coalition for Compassionate Care of California. POLST for Healthcare Providers. – Legislation & Public Policy. Retrieved September 2018, from https://capolst.org/polst-for-healthcare-providers/
5. California Health Care Foundation. (2009, January). CHCF Directs $2 Million to Spur Adoption of New End-of-Life Communication Tool - Recently approved POLST form gives seriously ill patients greater ability to control medical treatment. Retrieved September 2018, from https://www.chcf.org/press-release/chcf-directs-2-million-to-spur-adoption-of-new-end-of-life-communication-tool/
6. Dunn, P.M., Tolle, S.W., Moss,A.H., and Black, J.S. (2007, September). The POLST Paradigm: Respecting the Wishes of Patients and Families. Annals of Long-Term Care, 15 (9), 33-40. Retrieved September 2018, from http://www.polst.org/wp-content/uploads/2013/01/the+polst+paradigm+respecting+wishes.pdf
7. Pope, T.M., Hexum, H. (2012). Legal Briefing: POLST: Physician Orders for Life-Sustaining Treatment. The Journal of Clinical Ethics, 23(4), 353-76. Retrieved September 2018, from https://pdfs.semanticscholar.org/a142/bc9501f50610297654e085eeb9752da72e34.pdf
8. IOM (Institute of Medicine). 2015. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press.
9. Cantor, M.D., et al. (2002, August). To Force Feed the Patients With Dementia or Not to Feed: Preferences, Evidence Base, and Regulation. Annals of Long Term Care, Volume 10, Issue 8.
For additional information please contact Dr. Max Diamond at 714-221-5182 or mdiamond@regalmed.com.