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House Calls: End of Life: Think ahead about choices

House Calls runs monthly. Today’s column is written by Doris Fitch, a registered nurse at Sutter Coast Hospital and trainer at College of the Redwoods.

Patients often wonder about having all of their paperwork in order.  It’s important to take care of that ahead of time, when you are able.  It can provide more peace of mind if/when you are taken to the hospital. 

 

An advanced directive, also known as a living will, is a set of written instructions that a person gives in advance that specifies what actions to be taken for their health if they are not able to speak for themselves.  In addition, a power of attorney or health care proxy allows the person to appoint someone to make decisions on their behalf when they are unable.   

POLST (Physician Orders for Life-Sustaining Treatment) is an approach to improving end of life care in the United States, encouraging doctors to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis. This is a direct order for EMS to follow at the time of arrival. It can be revoked at any time per patient’s wishes or POA request.  This bright pink document gives specific treatment orders for health care workers to follow.

If EMS is called, it is like asking for life-sustaining help, so unless a POLST is visible they are obligated to resuscitate. Presently our end of life care includes EMS transport for comfort needs not met at home, so patients can comfortably access emergency care without the worry of major heroics.

Advanced directives were created in response to increasing sophistication and prevalence of medical technology. Aggressive medical intervention leaves nearly 2 million Americans confined to nursing homes, and over 1.4 million Americans remain so medically frail as to survive only through the use of feeding tubes.  As many as 30,000 persons are kept alive in comatose and permanently vegetative states. Cost burdens to individuals and families are considerable.

Further, studies indicate that 70-95 percent of people would rather refuse aggressive medical treatment than have their lives medically prolonged in an incompetent or other poor prognosis state.

The living will is the oldest form of advanced directive. It was first proposed by an Illinois attorney, Luis Kutner, in a law journal in 1969. Kutner drew from existing estate law by which an individual can control property affairs after death or when no longer available to speak for themselves. He devised a way for an individual to express his or her health care desires when no longer able to express health care wishes.

In the late 1980s public advocacy groups became aware that many people remained unaware of advance directives and fewer completed them. In response, further legislative support was generated in 1990 by way of the Patient Self Determination Act. This act required health care institutions to better promote and support use of advance directives.

 Living wills reflect a moment in time and need to be updated to ensure correct course of action at the time of need. They were originally  limited in scope and often failed to address problems so this led to a second generation advance directive, which added the health care proxy appointment or medical power of attorney.

The POLST (Physician Orders for Life Sustaining Treatment) was developed to improve end of life care in the United States. It encourages doctors to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis.

POLST was first introduced in Oregon in 1991 is currently promoted in over 26 states through national and statewide initiatives. The POLST can build on an advance directive but can also function in the absence of an advance directive. If the individual lacks decisional capacity, a surrogate can engage in the conversation and the consent process that forms the basis of the POLST process.

The difference between advanced directives and POLST is that the POLST is a medical order and actionable throughout the community. This form can be used by doctors and first responders including paramedics, fire department, emergency rooms, hospitals, home-health and nursing homes.

Studies show that adults are more likely to complete these documents if they are written in everyday language and less focused on technical treatments. Living wills, advanced directives and POLST have proven to be very popular.  By 2007, 41 percent of Americans had completed one of them.  

You can obtain a copy of the POLST at http://capolst.org/ or from your primary care provider, senior center or the hospital. When a patient, client or resident is placed in a facility, part of the admitting process requires us to offer, support and explain advance directives. You will be asked if you have one on file and if you do, we can bring it forward and place it in your chart if you are admitted to the hospital. If you do not have one, we can give you the paper work and help explain the process.

You can decline at any time but we are obligated to offer it to you. Advanced directives do not have to be notarized, but require two non-related witnesses. If you have your advanced directive on your chart while in the hospital, your nurse will place a purple band on your wrist saying DNR (Do Not Resuscitate).  This band makes your wishes known to all caregivers. Again you can change your mind at any time.

If you have advance directives it is advised you make sure you give a copy to all your health care providers, hospitals you visit for treatment, including your dentist.

Keep the POLST attached to your refrigerator. It is bright pink and easily viewed by EMS. They know to look for it. In addition, please keep a copy with you and or with your POA (power of attorney).

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