Healthcare directives
Protecting the medically vulnerable (including yourself!)
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Regardless of the state of your health today, you are at risk of harm from a medical institution.
Incidences of neglect and even intentionally-caused death are surprisingly common in healthcare settings and becoming more so as our society gives more value to its perception of someone’s quality of life than to his life itself.
When someone is unable to make medical decisions for himself -- for example in the case of a brain injury following an accident -- who decides his treatment plan? Some elements are straightforward at first: ensure that he has food, fluids, and oxygen. But what if he cannot swallow? Should a feeding tube be inserted or should he be sustained only with an IV? What if he cannot breathe on his own? How long should he be kept on a ventilator? Should he undergo a surgery that may kill him but could help him heal instead? Who makes these decisions?
If the patient has made no written instructions, hospitals may turn to his family members to decide. But what if his family members disagree? What if the hospital defers to family members with the closest blood relationship to the patient but who do not know or care what he would want?
Hospital policies concerning discontinuing life-sustaining treatment or even food and fluids may be in conflict with a patient’s wishes or the wishes of his family.
His survival could depend on the preparations he made before his accident.
If he has a completed a form giving someone the authority (“power of attorney”) to make medical decisions for him while he is incapacitated, that designated person can speak on the patient’s behalf and advocate for his treatment with the same force as if the patient were advocating for himself. The medical institution and family members, by law, must defer to the person with power of attorney.
(Life Legal Defense Foundation has written about the medical power of attorney here.)
If the patient has written instructions for his treatment in case of an incapacitating injury, the medical institution and family members should follow it, but might interpret it differently than the patient intended.
(One document that physicians routinely ask their patients to complete is the “Physician Ordered Life-Sustaining Treatment” form, also known by other names and abbreviated as a POLST, MOST, COLP, or TPOPP form. Read about the dangers of that form below.)
If the patient made no arrangements at all, or has only verbally indicated his wishes to his family members, the medical institution might defer to family members or might make its own decisions about what is in the patient’s best interest.
What’s wrong with the POLST form?
Let’s take a couple of examples.
The first time Dave visited his doctor after his 60th birthday, he was instructed to complete a “Physician Ordered Life-Sustaining Treatment” (POLST) form.
His doctor said that although Dave was in good health, the POLST form is now recommended for everyone over 60 years old and that it was important to have such a form in case he was incapacitated. The form allows a patient to indicate what measures he would like taken to resuscitate or sustain his life. Dave dutifully filled it out, indicating he wanted all measures taken to preserve his life. His doctor signed it, placed the original in Dave’s medical records and gave a copy to Dave.
When Susan visited the ER due to shortness of breath, she was asked to fill out a POLST form in the waiting room. She was distracted and anxious about her breathing and did not fully understand the questions the facilitator asked as he went through the form with her, but agreed to what he suggested.
What’s the problem?
The POLST form is designed for those at the end of their lives.
The POLST, also known as Medical Orders for Scope of Treatment (MOST), Clinician Orders for Life-Sustaining Treatment (COLST), and Transportable Physician Orders for Patient Preferences (TPOPP), usually printed in a bright pink or other eye-catching color, is a medical order. The patient is advised to mark which measures he would like medical personnel to take to revive him in the event he is medically incapacitated, designate his doctor as having the final say on the matter, and then carry the form with him or put it in a prominent place, such as hung on the refrigerator, so that paramedics will see it if called to assist him.
Medical professionals no longer assume that a patient wants his life sustained or, even if they know he does, they may not believe it is a good thing for his life to be sustained. Hospital policies concerning discontinuing life-sustaining treatment or even food and fluids may be in conflict with a patient’s wishes or the wishes of his family.
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The POLST form originated as a type of portable, easily accessible do-not-resuscitate form for those who are terminally ill or seriously chronically ill and not likely to improve. It carries with it the assumption that the patient does not want medical personnel to do everything they normally would do to revive someone and keep them alive. Signing a POLST may be a reasonable choice for seriously ill people who do not want extraordinary measures to be taken to pull them back from the brink of death as their condition deteriorates. But POLSTs are now routinely offered to healthy people, like Dave, sometimes as a condition of admission to hospitals or other care facilities, and evolving medical norms have made them dangerous.
For example, some patients may misunderstand the form. Susan was asked by the facilitator if she wanted “comfort care” and said she did, not realizing that comfort care means halting treatment and simply minimizing pain as someone dies. The facilitator checked boxes on the form that indicated that Susan declined life-sustaining measures.
Since the POLST is a medical order, the physician gets the final say in interpreting it and the patient’s wishes concerning resuscitation and life-sustaining treatment.
For the average patient who wants to live and who would like to be revived if he suffers a heart attack or is in a car accident, the POLST form is worse than useless. If he fills it out indicating he would like all regular measures to save his life, the form will do nothing for him except possibly slow paramedics down as they read the form and study his preferences before reviving him. If they don’t study it, they may view it as a do-not-resuscitate form and let him die.