Living Wills and POLST: Take Charge of Treatment Preferences and Choices
End-of-life care discussions need to begin when you are healthy and independent and should be part of every individual’s estate plan and health care treatment plan. Communicating your wishes with your family and having the proper documents in place will improve the end-of-life experience for you and your loved ones. According to a 2016 Rutgers-Eagleton/New Jersey Health Care Quality Institute Health Matters Poll, six in 10 New Jerseyans have not put their end-of-life care wish in writing.[1] About half of residents know about Advance Directives, less than a third know about POLST.[2]
An Advanced Directive protects your right to refuse medical treatment you don’t want or to request treatment that you do want, in the event you lose the ability to make decisions yourself. What is POLST? And if I have an Advance Directive, when and why would I need POLST?
Advance Directives:
Every competent adult, regardless of age, should have an Advance Directive. The New Jersey, Advance Directives for Health Care Act, allows you to select an individual who may act as your healthcare proxy or representative[3]. The Advance Directive Act gives your proxy the legal authority to make decisions on treatment when you cannot make your own decisions. In addition, your Advance Directive may provide an instructional roadmap to your providers, establishing a framework of your treatment preferences.
The Proxy Directive portion of the Advance Directive permits you to select almost any adult to serve as your health care representative.[4] Operators, administrators or employees of a health care institution where you are a resident or patient may not serve—unless that person is related to you.[5] Your health care representative may be instructed to consult with specific individuals during the course of the decision-making process and you may place limits on the authority of the health care representative.
In addition to the Proxy Directive, you may also include an Instructional Directive as part of your Advance Directive. In that portion of the directive, you may state your general treatment philosophy and objectives and/or specific wishes regarding any form of healthcare including life-sustaining treatment.[6] For example, you may instruct that given certain circumstances you do not want to be artificially provided fluids and nutrition like feeding tubes or intravenous infusion.
There are limits; however, to Advanced Directives. Advance Directives require evaluation by a physician regarding your diagnosis and prognosis in the context of your treatment preferences.[7] That takes time. It also requires that someone locate the Advance Directive and provided to the physician. Often the Advance Directive is in a drawer or safe-deposit box and not readily available. As a result, sometimes it cannot be located before treatment is started. Additionally, the language in an Advance Directive is often ambiguous and unclear, “if I have a terminal condition . . . .“ Advance Directives are not operational in an emergency or by first responders because they require time for evaluation and interpretation by a physician.[8]
Even with their limits, Advance Directives are an important piece in the end-of-life plan. They afford you an opportunity to communicate your preferences to family and friends and are useful in the pre-operative setting. In addition to having an Advance Directive, it is paramount that you communicate your wishes to your health care representative and your family. A well-informed family can advocate for you and communicate your wishes to health care professionals.
POLST:
POLST is an acronym for Practitioner Orders for Life-Sustaining Treatment. The POLST form complements an Advance Directive by converting a person’s wishes regarding life-sustaining treatment into medical orders.[9]
The POLST form is completed by your physician or advanced practice nurse after consultation with you or your representative. You or your health care representative, if you cannot communicate your wishes, also sign the document. The POLST form is straightforward and addresses: 1) your goals of care; 2) medical interventions; 3) artificially administered fluids and nutrition; 4) CPR and intubation. You can click here to view New Jersey’s POLST form.
POLST is recommended for: individuals who are seriously ill with life-threatening advanced illness; individuals who have significant weakness and advanced frailty; individuals in long-term care facilities; and individuals with strong preferences about medical interventions in their end-of-life care.[10] POLST is not indicated for healthy individuals as a “what if” plan.
In a facility, the POLST form will be part of your readily accessible records. At home, the bright green form should be placed where first responders are likely to see it: on the front door, next to your bed, on the fridge. You should have an original copy of the POLST form with you at all times.
Individuals have right to make their own health care decisions including deciding about life-sustaining interventions: surgery, PEG tube feeding, antibiotics, ventilators, dialysis, etc. Moreover, individuals can work with their providers to set forth a plan for comfort care. Beginning with an Advance Directive and culminating in POLST orders. New Jersey individuals can take control of their medical treatment. It all starts with a conversation.
[1] http://eagletonpoll.rutgers.edu/rutgers-eagleton-nj-health-care-quality-institute-end-of-life-apr2016/
[2] Id.
[3] N.J.S.A. §26:2H-56 et. seq.
[4] N.J.S.A. §26:2H-58
[5] Id.
[6] Id.
[7] N.J.S.A. §26:2H–59
[8] N.J.S.A. §26:2H-70
[9] N.J.S.A. §26:2H-130
[10] POLST Guidance for N.J. Healthcare Professionals, New Jersey Hospital Association, http://www.njha.com/quality-patient-safety/advanced-care-planning/polst/