or Imposed Death?
November 30, 2010
“POLST” is short for “Physician’s Orders for Life Sustaining Treatment.” It is a so-called “advance care planning” document; a page or two of medical instructions designed to follow a patient from one setting to another. In Oregon the form is still called POLST, but in other states it has taken on a variety of names such as POST, MOLST, or MOST. It was devised for sick and elderly people, and lists treatments they might wish to forgo. Any patient in a nursing home or a patient with an “advanced illness” would qualify. Emergency teams and first responders are trained to use POLST. When the patient’s condition worsens, or when the patient is transferred to a new location, the POLST form is reviewed and the patient is asked again whether he/she really wants antibiotics, “artificial” hydration/nutrition, and so forth. The check marks on the page are instantly transformed into “physician’s orders” or “medical orders.”
By design or not, POLST is also an effective cost containment device. Earlier this year POLST’s designers at the OHSU Center for Ethics in Health Care issued a Statement on the Fiscal Impact of the POLST Paradigm, maintaining that (emphasis added): “an ideal health care system would honor individual preferences while allocating health care resources efficiently.” The report went on to demonstrate that in numerous studies POLST increased efficiency by preventing “expensive hospitalizations.” 
Autonomous? Think coached.
The bioethicists who devised the POLST Paradigm hyped the documents’ use as tools for dignity and autonomy.  The documents do leave the door wide open to an “autonomous” decision to hasten death. This is particularly true in Oregon and Washington where “comfort care” includes assisted suicide.
However, assisted suicide is only one concern. POLST is more apt to facilitate imposed death
POLST owes its existence more to Oregon’s experiment with health care rationing than it does to the state’s assisted suicide experiment. In fact, POLST grew out of an effort in the late 1980s by Portland area hospital ethics committees (not patients) who were considering how to limit “futile treatments.” Eventually ethicists came up with a document that would discourage providers and patients from requesting treatments that were “not medically indicated” – i.e., treatments not considered appropriate by a panel of “experts.”
Shortly after Oregon’s legalization of assisted suicide in 1994, the document was given a name that tested well in focus groups, emphasizing that these were orders “for life-sustaining treatment.” The document was fine-tuned under the direction of an ethicist mentored by Mark Siegler of the MacLean Center for Clinical Medical Ethics at the University of Chicago (where Valerie Jarrett’s father was senior scholar). To assist in testing and implementing the document, the bioethicists engaged the help of Oregon Health Decisions — a group of community organizers and left-leaning activists who had formed Oregon’s “citizen parliaments” that created Oregon’s infamous rationing lists.
Who funded it?
Perhaps it is no surprise that George Soros’s Project on Death in America was one of the earliest funders of the POLST venture at OHSU. Among other funders were the Greenwall Foundation, the Robert Wood Johnson Foundation, and Nathan Cummings Foundation. At the time, the Cummings Foundation was also funding Ezekiel and Linda Emanuel for a study of caregivers’ burdens. The Greenwall Foundation was known for its funding of bioethicists who favored “death with dignity.” Later, in 2008, Greenwall would also grant $40,000 toward a study on how to determine which Alzheimer’s patients should be allowed to vote. Recipient of the grant was Charles Sabatino – director of the American Bar Association’s Commission on Law and Aging, and POLST activist.
Following is a sketch of what POLST is and is not:
POLST is not a traditional “legal transaction”
- Although a POLST form looks like a contract, usually displaying signatures of patient and provider, it is not a traditional legal transaction. Charles Sabatino says POLST reflects a “paradigm shift from [the traditional] legal transactional model to a communications model.”
- POLST does not require a physician’s signature; nor does it require the signature of the patient or proxy. The POLST Paradigm Task Force “recommends” that POLST require a patient/proxy signature, but the signature is definitely optional, depending upon regional requirements.
More like “a process”
- POLST is not so much a document as it is “a process.” One advisor to the Senate HELP committee made the pitch for POLST last summer: “The process of completing a POLST form is [not only] a values clarification process, but one that results in specific and explicit medical orders” 
- “The process” is repetitive and often conducted when the patient and proxy are under duress, as the patient’s condition changes. In many states, the form has multiple lines for multiple interviews. “The process of goal clarification requires intense, time-consuming, face-to-face conversations with patients and/or family members” triggered by what the providers perceive should be “realistic options” for care.
- “The process” can be initiated by someone other than a physician, and that is usually the case. According to POLST advocates, “nurses, social workers, admissions coordinators, and nursing home administrators are typically the front-line implementers of POLST. They facilitate POLST discussions at the time of admission (or sometime later), record patient preferences, and then refer the form to the physician for signature.” This means that on one day a Catholic physician might counsel his patient to request hydration, only to find that, on the next day, an admissions coordinator or social worker reviewed the orders with the patient (or proxy) to “clarify” away the previous day’s decision.
What triggers “the process”?
- The definition of an eligible candidate varies widely. A recent National POLST Paradigm report suggested POLST is triggered by “advanced illness.”
- In some states, health care professionals are trained to identify prospects by asking themselves the question, “would you be surprised to see this person dead in a year?” (a prompt that was devised by a physician at Franciscan Health System West — one of the health systems that participated in Donald Berwick’s “Improving Care at the End of Life Collaborative ).
Are the documents legal in every state?
- The documents’ legal status vary dramatically from state to state. In Oregon, for example, POLST couldn’t move forward without passage of liberalized surrogacy laws. Even after that, the task force decided to bypass the legislature to gain full implementation, and so pushed for a liberalized rule from the Oregon Board of Medical Examiners. The new rule provided “both a mandate and a legal shield” for first responders, who would be key to implementing POLST. Susan Tolle, MD, of the POLST Paradigm Task Force warned “the POLST form functions within the context of Oregon’s liberal advance directives law and would require modification for use in some other states (for example, those without surrogacy provisions)”
In Washington State, the advance directives statute had prohibited surrogate decision-makers from making Do-Not-Resuscitate (DNR) decisions for a patient. With pilot-testing already in progress, POLST activists stepped in and pressured the state’s Department of Social and Health Services (DSHS) to reinterpret the statute. With the help of local media and “frightening articles in major media,” DSHS revised their interpretation and approved POLST.
- Though the applicable laws and regulations vary dramatically from one state to the next on issues such as surrogacy, assisted suicide, scope of practice for first responders, POLST activists are working toward making the documents “fully transportable,” i.e., forcing states to honor out-of-state documents.
Goal-oriented process. Whose goal?
The problem with POLST is not that it allows patients to hasten their own death. The problem is that POLST facilitates imposed death. It creates an illusion of “self-determination” while fostering consensus ethics. It is vague as a legal document, and the iterative, goal-oriented process is designed to reduce the use of what some ethicists call “inappropriate” treatments, but what others may call ordinary and life-enhancing. The documents may be used by a wide range of health care workers, many of whom do not know the patient personally. In short, the POLST process rigs the system in favor of pressuring the patient and family.
Although not writing about POLST specifically, bioethicist Wesley J. Smith has illustrated the effect of this sort of process:
I hear often from people who believe they or their aged/ill/disabled loved ones are being pressured into refusing treatment–usually not by being brow beaten or yelled at–but from a constant, drip, drip, drip of conversation after conversation after conversation, which only end when the patient agrees to what the doctor or ethics committee want. In this phenomenon of the never-ending-conversation, people often perceive an attempt to wear them down by sheer exhaustion into acquiescing.
Smith’s “drip, drip, drip” sums up the POLST process rather well.
 The National POLST Paradigm Task Force., Statement on the Fiscal Impact of the POLST Paradigm (Portland, OR: Center for Ethics in Health Care, Oregon Health & Science University, 2010).
 Lewis-Husk, Lee, and Michael J. Garland. The First Decade, ed. Susan W. Tolle and Gary T. Chiodo. Portland, OR: The Center for Ethics in Health Care, Oregon Health Sciences University, 1999. Also: Myra J. Christopher and Jeri Spann, “Oregon Health Decisions: Lighting the Way to Common Ground,” State Initiatives in End-of-Life Care, October, 1998.
 Patrick M. Dunn and others, “A Method to Communicate Patient Preferences About Medically Indicated Life-Sustaining Treatment in the out-of-Hospital Setting,” J Am Geriatr Soc 44, no. 7 (1996).
 Charles Sabatino and Myra J. Christopher, “Advance Planning: From a Transactional Model to a Communications Approach (Slide Presentation),” in The Changing Face of Health Decisions (American Bar Association, 2008).
 Oregon POLST Task Force, “Guidance for Oregon’s Health Care Professionals,” (Portland, OR: Center for Ethics in Health Care at Oregon Health & Science University, 2009).
 Diane E. Meier and Larry Beresford, “POLST Offers Next Stage in Honoring Patient Preferences,” J Palliat Med 12, no. 4 (2009).
 Myra J. Christopher and Jeri Spann, “Implementing End-of-Life Treatment Preferences across Clinical Settings,” State Initiatives in End-of-Life Care, April 1999.
 Susan E. Hickman and others, “The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation,” J. Law Med. Ethics 36, no. 1 (2008).
 Christopher and Spann, “Implementing End-of-Life Treatment Preferences across Clinical Settings.”
 Susan W. Tolle, “Care of the Dying: Clinical and Financial Lessons from the Oregon Experience,” Ann Intern Med 128, no. 7 (1998).
 Judy L. Meyers and Rose Mary Volbrecht, “The Story of the POLST Form: How a Grassroots Effort Can Make a Difference in End-of-Life Care,” DNA Reporter (Delaware Nurses Association) 30, no. 2 (2005).
 Wesley J. Smith, “”Obamacare: Column Illustrates the Potential for ‘Never Ending Conversation’ End of Life Counseling Pressure,” in Second Hand Smoke (http://www.firstthings.com/blogs/secondhandsmoke/2010/04/04/obamacare-column-illustrates-the-potential-for-never-ending-conversation-end-of-life-counseling-pressure/, 2010).