Beyond the Advance Medical Directive

My mom, 88 stubborn years old, still lives on her own in a big house with a cat that loves to get underfoot. Because I work in health care, I have an all-too-vivid recognition of the perils that can befall someone in her situation. So, posted on her kitchen bulletin board is a bright pink sheet of paper called a POLST.

POLST stands for Physician Order for Life-Sustaining Treatment. It’s a document that makes your treatment wishes known to doctors, nurses, emergency medical technicians, and other health-care providers. Too often, people near the end of their lives get treatment they don’t want. These treatments may not help them live longer or better, and sometimes they can cause pain.

Also, family members sometimes have their own ideas about what types of treatment their loved ones would want. POLST makes sure your family members and caregivers know exactly what life-saving treatments you do and do not want. Doctors say any seriously ill person should have a POLST. Filling out a POLST is completely up to you. It’s your choice.

POLST is different from an advance health care directive. An advance directive allows you to choose the advocate you want to speak for you if you’re incapacitated, and it provides a general guide to what treatment you want. POLST is different because:

• POLST is a signed medical order that your health-care team can act upon, whether your advocate is there or not;

• POLST indicates your exact wishes about certain medical treatments.

Although it’s a good idea for all seriously ill people to have both an advance directive and a POLST, any adult, especially if she or he is unmarried, should have one or both.

You can find the POLST form online or at your primary care provider’s office. Your provider can explain the different options on the form to you. The POLST must be signed by a licensed healthcare provider and by you. Some states require a witnessing signature as well.

Once signed, the POLST becomes part of your medical record. It stays with you all the time. If you’re at home, put it near your bed or on your refrigerator. If you’re in a hospital, nursing home, or assisted living facility, it’ll be in your chart or file. If you’re moved between locations, your POLST goes with you.

POLST forms vary by state and focus on three types of interventions. For each, you can chose whether or not to have something done or choose a level of intervention.

• Resuscitation (person has no pulse and is not breathing): Cardiopulmonary resuscitation, or CPR, is done to try to start your breathing and heartbeat after they stop. CPR involves chest compressions and/or electrical shock to try to start your heart again. It may also involve having someone breathe for you. Resuscitation can benefit healthy young people, but it’s not usually helpful for seriously ill or elderly people. You can choose to accept or decline resuscitation.

• Medical intervention (person has pulse and/or is breathing): Interventions can include CPR, intubation (a tube down your throat to open your airway), mechanical ventilation (a machine to pump air in and out of your lungs), medication/antibiotics, fluids, monitoring, and a host of other things. You can choose a level of intervention, from full treatment to comfort measures only.

• Artificially administered fluids and nutrition: This is a way of feeding a person through a tube either in his/her nose or through the skin into his/her stomach. Tube feeding can help people who can’t swallow now but are expected to get better. However, people near the end of life may feel more comfortable without a feeding tube and want to eat what they can by mouth. You can choose a level of intervention, from long-term nutrition to a defined period of nutrition to hydration-only to no intervention.

It’s important to fully understand these and other options, so make sure you talk to your doctor, nurse practitioner, or physician assistant before you make any decisions. You can then choose what treatment options you want and don’t want. You can also adjust your POLST at any time, as circumstances change.

The POLST website in California, where you can get more information and download forms, can be accessed at capolst.org.

More information on advance directives can be found at medlineplus.gov/advancedirectives.html.

Cate Kortzeborn is Medicare’s acting regional administrator for Arizona, California, Hawaii, Nevada, and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).