Somewhere along the way I learned to believe that if a declaration is written down on physical paper and signed, it carries with it an almost magical certainty of follow-through: it can be framed, cited, stored in a safe, and, if need be, brandished in a court of law. This is an interesting idea in the realm of advance directives.
Well-intentioned advance directives
The goal of an advance directive is to protect patient autonomy. Patients can document the extent of medical care they would like to receive if circumstances render them unconscious or otherwise unable to express their wishes. Patients can designate surrogates, but to be clear, the idea of documenting ‘comfort measures only’ in an advance directive seems more hopeful than practical.
In a recent New York Times article, the author explains the fallibility of advance directives in an emergency setting. In practice, emergency medical responders have standing orders to resuscitate. This allows for the time to stabilize and assess a patient’s state of health by clinicians in a hospital setting before moving forward. Decisions that may impact the remainder of a patient’s life deserve to be made in a timely yet deliberate manner and with as much information as can be gathered from loved ones and hopefully then from an advance directive.
The POLST in a pinch
The POLST or physician orders for life-sustaining treatment is a state health initiative, pioneered by Oregon and West Virginia and now in the works for nearly forty of the fifty states, with some variation in name from state to state. The difference between an advance directive and the POLST is that the POLST is a physician’s order, signed by an MD, DO, nurse practitioner, or physician’s assistant. It is meant to travel with a patient across care facilities — hospitals, skilled nursing facilities, and hospice — and can be easily accessed by emergency medical services through an electronic state registry. A POLST order, but not an advance directive, can signal emergency services to not resuscitate a patient. The POLST is a wonderful example in its implementation of how interdisciplinary care can coordinate around a patient’s preference.
The Oregon POLST (PDF) is a one page, double-sided document, divided into three sections. A patient can decline CPR in the event that they are found not breathing and without a pulse, but can still request full treatment if they are found breathing or with a pulse. The distinction is an important one for many people, and one which is respected by this type of documentation.
A caveat, however, is that a POLST is only meant for patients believed to have a prognosis of six months or less. Both the patient (or patient surrogate) and provider must sign the document. The POLST is at its heart a tool to ensure that people who are close to death, who do not want to die in the hospital, are allowed a thoughtful yet timely discussion of their desires with the pre-existing knowledge of their prognosis.
Who is in charge?
Now that we have this tool, who is responsible for using it? In team-based medicine, we worry about bystander effect: if a patient has an oncologist, a primary care provider, and a palliative team, who should put it on their list of responsibilities to review the POLST with the patient? Common sense says that this should be a non-issue, that by nature none of the providers are “bystanders.” Yet even at my novice stage in medicine I’ve already heard a handful of stories about patients who are known to have extremely poor prognoses who were not explicitly told by their doctors, often because those doctors believed another provider had already had the conversation.
In a recent article in NEJM, three physicians write to address the different vantage points of this exact vignette. The authors submit reasons for why either the primary, the specialist, or the palliative team should bear the responsibility; the primary arguing for continuity as the best vehicle for this discussion, the specialist that they have sub-specialty knowledge of prognosis, in addition to having formed a relationship with the patient through a challenging life event, and the palliative proponent for their background in specialized communication training and a needs-driven care model. All three proposals seem to make sense.
It is clear that each provider has something unique to contribute to a conversation with a patient. One author adds that “with a high-functioning team, it may not matter whether [the patient] talks first to an oncologist, to a palliative care physician, or to her primary care physician. In the best case, all of [the patient’s] clinicians would contribute their particular expertise and personal touch at this pivotal time.”
I wonder instead of asking who is responsible, why aren’t we asking how we can form more effective interdisciplinary care teams for our patients?
Heather Alva is a medical student. This article
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