Scenario One: Your 74 year dad, hardworking guy, now retired from the mill, is in poor health. He started smoking at age 15, and has been weakened by heart disease since shortly after his retirement. A year and a half ago he was diagnosed with lung cancer. After some initial response to treatments, his cancer seems to be growing faster, and he's decided not to pursue any further therapy. He filled out an advanced directive (AD) back when his cancer was diagnosed. His wife is his durable power of attorney, and she's been getting a tad forgetful of late.

One fall day, while you are visiting your daughter who is away at college, dad takes a rapid turn for the worse. He can't seem to get his breath. Your mom calls 911, and by the time the paramedics arrive, he is really struggling to breathe, and can scarcely speak. Your mother is in a panic as they bundle dad off to the emergency room. In route, his situation deteriorates to the point that a breathing tube is inserted into his windpipe. When the dust settles at the hospital, dad is in the intensive care unit on a ventilator to support his breathing. He has a terrible case of pneumonia. You race back to town, get a bead on the situation. You meet with the doctors and discuss the poor prognosis, especially given his background health. Even before you think of it, one of the docs asks if your dad had an AD. “Yes, its somewhere at home.” You are next asked whether your dad had made a declaration about life support. “Well, I'm pretty sure he did not want to be on any machines or anything...”

Now you are in over your head. Rather than the “easier” decision NOT to start the life support, you have the wrenching issue of withdrawing it. Turns out dads AD is a little vague on life support – but seems to indicate that he'd not want it if he had little or no chance of a meaningful recovery. On his third day in hospital, dad has a heart attack, and deteriorates further. With a tube in his throat he cannot talk, and he is sedated all the time in order tolerate the breathing tube. Your mom cannot bring herself to a decision regarding how long to continue the ventilator. Your older sister is adamant that this “is not what dad would want”, while your baby brother is hinging his hopes on a TV show he just saw in which a guy survived after months on life support. Impasse. On his sixth day in the hospital, your dads heart becomes unstable, his blood pressure drops in spite of all measures, and because no decision has yet been reached on cardiopulmonary resuscitation, chest compressions are begun. The family is rushed in for an urgent conference, and a decision made to stop CPR. Your father passes away shortly thereafter. He sustained multiple rib fractures during the chest compressions and never regained consciousness.

Scenario Two: Starts out like number one, except that when you father found out his cancer was worsening, he completed a POLST form. He made it clear to his wife and family that he did not want any life sustaining treatments outside of a trial of antibiotics if he got an infection. He was OK with the idea of going to the hospital. He wanted no mechanical ventilation nor CPR. When he got sick with pneumonia and the paramedics called, his POLST wishes were readily available, so a breathing tube was not inserted. Some “non-invasive” measures to support his breathing were tried, and antibiotics started. He was not taken to the intensive care unit – rather, he was admitted to a less chaotic part of the hospital, and a nurse with skills in end of life care was assigned to him. His comfort was the priority. He responded to the antibiotics, at least for a time. Without the stress of the ventilator, his heart condition did not deteriorate as seriously. He was surrounded by family and friends. On his fourth hospital day, he decided he wanted to go home with hospice nursing care, and passed away two weeks later. In that time, his grandchildren had time to visit, and he relayed and recorded many previously untold childhood stories.

So what is this POLST thing, anyhow? It is your typically clumsy medical acronym, and stands for a Physicians Orders for Life - Sustaining Treatment. This long-overdue program – which has really taken off of late – started in Oregon in 1991. The purpose was to create a standardized, portable physician/ medical order that legally documented ones treatment wishes. Here is what Montana's and most forms look like: http://www.dphhs.mt.gov/sltc/services/vethome/MVHForms/POLST.pdf

A POLST declaration does not in an of itself limit care. What it does do is legally document ones care desires, and quite specifically so for critical issues like resuscitation and hospitalization. It allows - in fact, requires - ones desires for care to be respected by paramedical personnel, emergency room providers, hospitals, and other care givers. In the past, absent a visible, officially recognized and legal “medical order”, ones wishes, even in the too-rare instance that they were documented and found, were often ignored. Medico legal concerns, shifting family preferences, caregiver biases and myriad other circumstances led to their violation. The POLST goal is to eliminate scenario one.

Who should have a POLST form? Anyone with a life-limiting or terminal illness should consider this. Most long term nursing home residents are candidates. A rule of thumb for providers which POLST organizers in Oregon suggested is the following: “would I be surprised if this patient died within the next year?” If the answer is no, this individual should be considered for a POLST.

These forms are completed only after a lengthy – generally 45 minutes to one hour – consultation with providers trained in the process. Both the patient and their legal representative/DPOA should be present for this conference. The purpose of that visit it to be clear about the forms purpose and significance, and to answer the many questions that this crucial discussion brings forth. In some instances, the discussion may be led by the patients primary care provider, though time constraints in the typical office practice are likely to make the completion of the POLST a separate process, perhaps performed by a panel of trained providers.

A POLST form is meant to compliment rather than replace the AD. The living will section of the AD can add significant further detail in terms of care wishes and philosophy, but it cannot function as a recognized, enforced medical “order.” The living well is the background for the POLST.

The state of Montana is currently in the development stages of the “POLST Paradigm.” There are numerous hurdles to overcome to roll this out on a statewide basis. However, the forms are already available, and a great number of patients, including many nursing home residents in the state of Montana, have had POLST forms completed.

So....if you or a loved one suffers from a life-limiting illness and you want to both clarify and legally document your care preferences, go to the following link, educate yourself on POLST, and strongly consider filing an official form.

An excellent place to start in terms of educating yourself on this excellent program is the following:
http://www.ohsu.edu/polst/

Stan Seagraves M.D., an internist who has practiced in Missoula for over 20 years. He is currently practicing hospital medicine at St. Patrick Hospital, and is medical director of their hospitalist program.

SPECIAL GUEST COMMENTARY: This contribution was made solely for the benefit of readers of this web-site and is not an endorsement of GIIG, it’s products or services.