Implementing California’s new “POLST LAW”

1. POLST stands for Physician’s Orders for Life Sustaining Treatment. This form should be used to document the end-of-life conversation you have with the patient or their representative. This form should be used with those who with a terminal illness or approximately 1 year of life remaining.
2. If you are unsure if someone is within one year of death, ask yourself, “Would I be surprised if this patient wasn’t alive a year from now?” If the answer is no, I wouldn’t be surprised, then start having end-of-life conversations and use the POLST form.
3. POLST does not replace the advance directive. Instead, it supplements it by taking the requests of the patient, with physician approval, and puts the requests in action. An Advance Directive is still needed to document who should be the surrogate decision maker, other medical treatment requests or refusals and patient wishes regarding organ donation and/or autopsy.
3. It can be used in the ambulance, hospital, nursing home, board and care and patient’s home. Because it works across healthcare settings, there is clear communication regarding the patient’s wishes and continuity of care.
4. It replaces the Pre-hospital DNR in outpatient settings. It addresses more than a DNR. It also addresses: comfort care orders, level of treatment desired, whether to transfer patient to the hospital, antibiotics and artificial nutrition and hydration.
6. It must be signed by the physician and the patient or their representative. If the representative is out of town, you will need to fax the form to them and have them sign it.
7. Most importantly, by law, if you are presented with a completed POLST form, you MUST FOLLOW IT.
8. The only exception is when the request on the form is requesting medical care that is outside the standard of practice and would be medically inappropriate or non-beneficial. If you are going to reject what is written on the form as a request for bad medicine, you may want to protect yourself as you are going against the POLST law. You should discuss this with the bioethics committee or the legal department of the hospital.
9. You don’t have to use this form if you don’t think filling it out would be appropriate for your patient. But again, you do have to follow it if the patient presents it to you.
10. A patient or their representative can change their mind and void the POLST form. You should draw a line through the form and write VOID on it. If the patient has lost capacity, the surrogate decision maker can void this form. Do not take this decision lightly. The patient voiced strong opinions about their choices, their doctor agreed with their choices and the wishes were documented into physician orders. Be cautious when evaluating whether the surrogate is expressing the wishes of the patient or their own wishes.
10. When you are going to use the form, it must be printed on bright pink paper. The bright pink form is then given to the patient to take home or back to the nursing home with them. You should keep a white copy in your chart. You should also make sure the document is forwarded to the patients other healthcare providers and a copy should go in the hospital chart. You may also want to have the patient put a note in their wallet saying that they have a POLST form and where it can be found.
11. The patient should keep their pink form either on their refrigerator, in their medicine cabinet or at their bedside. The best place is on the refrigerator so the EMT’s can find it.
12. If a patient has a POLST form and an Advance Directive that requests different treatments, the most current form should be followed.
13. This form is to be used, not only to refuse treatments, but to request treatments as well. When talking to the patient about their wishes, instead of saying, “Do you want us to do everything?” please ask, “Would you want us to do what is medically effective?” This will help the patient realize that there is a difference between everything and valid medical options. You should also ask about where they would want to die and how they would want to die. You can ask, “Would you want us to allow you to have a natural death?” AND or Allow Natural Death is the new language to use when talking about DNR’s.
14. For more information on POLST go to FinalChoices.org. You can also download the POLST form at http://finalchoices.org/docs/CA%20POLST%20Form%202009.pdf Final Choices also has a brochure you can download to give to your patients.
15. Lastly, when you are ordering comfort care measures in the home or nursing facility, realize that there may become a time when the comfort of the patient can not be handled in the outpatient setting. If you do need to transfer the patient back to hospital, only treat the uncontrolled symptoms, do not admit the patient into the ICU or increase their level care in order to “cure” them. The goals of care haven’t changed, just the location.

Got a question? Ask Viki.

How do I get my loved one on Hospice?

Viki,

How do I get my husband into hospice? He has cancer which has spread everywhere and his pain is not being managed. I have heard about hospice but I don’t know who to call. What can I do?

I am so glad you asked. To get a patient on hospice, a doctor has to make the referral to the local medical hospice. You have to ask your husband’s doctor, and it could be any of his doctors, to call hospice and set it up. Some doctors are not willing to put their patient on hospice because they don’t want to give up trying to save your loved one. So if your husband’s doctor won’t put him on hospice, ask another doctor you know. An ER doctor can also put someone on hospice.

After the doctor calls hospice, the hospice representative will call you later that day or the next morning. A social worker and a nurse will both be coming out to see your husband within 24 hours. They will evaluate what needs your husband has and what your family may need. If your husband qualifies for hospice, you will start receiving visits from other hospice staff, deliveries of medical supplies such as hospital beds, oxygen or bedside commodes. You will also be receiving medications to have available to take care of his pain and other symptoms. And the good news is that none of this will cost you anything.

The nurse will teach you about the new medicines and there is a 24 hour hotline you can call if his symptoms change and you need help. Every patient is different. What your husband will need may be very different that what my Dad needed. The good thing about hospice is that as patient’s health needs change, they can adapt the plan and continue to provide comfort for your loved one.

It may be overwhelming for the first few days as so many caregivers will be coming and going as they make sure your husband is well taken care of. Unfortunately, you do lose some privacy which takes some time to get used to. Don’t worry though, after a while you will get to know the hospice team and they will become your trusted friends. Most people find hospice to be a huge comfort to them as they can know that their loved one won’t be suffering.

Got a question? Ask Viki.

Unethical behavior on Grey’s Anatomy

This won’t be the first or last time I will need to comment on unethical behavior on medical shows.

I am never surprised to see unethical medical behavior on television but I worry that the general public will think that this is how medicine is done.

Grey’s Anatomy had an episode last week in which one doctor went to speak to a patient’s loved one about donating their organs to a young boy who was dying. That would never happen in a non-TV hospital because doctors are not allowed to speak to the family about organ donation.

The only person who should be talking to the family is the representative from the local organ procurement agency. This protects doctors from having a conflict of interest by having to be both the person who is trying to save the patient and the person trying to take the organs after the death.

Another unethical thing that happened was what occurred after the doctor asked the wife for her husband’s organs and the wife said “no”.

Since other organs weren’t available for the dying boy, the doctor went back and put more pressure on the wife. This wouldn’t happen either. In medicine, we are supposed to respect people’s decisions, especially when they say no. Organ donation can not be a coercive process. You can ask, but you can’t push or force people to decide to donate their organs.

To make sure your family isn’t put in this situation without knowing your wishes, make sure you tell people what you would want in that situation. If you want to donate your organs after your death, then register your wishes with your local department of motor vehicles either online or in person. If you don’t want to donate, then you should write that down in your advance healthcare directive.

I believe in organ donation because organ donation saves lives. Maybe someday it will save yours.

Got a question? Ask Viki.

Why Did the Doctor Run Away?

Dear Viki,

“The doctor stopped coming into my grandpa’s hospital room and never came back to check on him. Luckily the nurse was there and helped our family as we didn’t know what to do. Viki, why did my grandpa’s doctor run away when my grandpa was dying?”

Maybe the doctor didn’t really “run”, but to the family, it felt like the doctor ran away and became invisible as the end approached. I don’t think doctors mean to do this, but unfortunately, doctors can be uncomfortable around death.

I know, you’re saying, “How can that be?” Well, it is easy. Those who are drawn to medicine and want to become a doctor are those who want to heal and to save. Nobody becomes a doctor to help people die. But unfortunately patients do die and doctors would rather not be a part of it. Unless they get specialized training, their discomfort with death doesn’t go away. Luckily, the young doctors coming out of medical school are getting better training regarding taking care of the dying.

Thank goodness for the nurses who take such good care of our loved ones as they die. Sometimes the best we can do for our loved ones is to have a good nurse, a good chaplain and a good social worker to make the experience a little better. Over the next few months, I will be discussing the concept of a “good death” in greater detail.

Feel free to contact me with your death and dying questions.

The Unbefriended Senior

What is an “Unbefriended Senior? The “unbefriended” is a word used to describe someone who doesn’t have any friends or loved ones in their lives that the doctor can talk to when the patient is sick or injured. This term could also apply to someone younger without any family or friends.

Let me tell you about what just happened. An 80 year old woman collapsed at the market and was brought to the emergency room. She has had a massive stroke and may not live. The social worker looks through the patient’s wallet to find her insurance card and any information about who to contact in case of an emergency. Only the insurance card and an address are found. The social worker begins to make calls, goes to the patient’s house and tries to find anyone who might know this person. But nobody is found.

So what can the doctors do? If the patient gets better, then the patient will be able to speak for herself but if she doesn’t wake back up then the doctors will have to apply the “Best Interest Standard.” What is this? The Best Interest Standard is used when the healthcare team doesn’t know what the person would want and when nobody is available to talk to.

The healthcare team and possibly the bioethics committee will meet to evaluate what medical options are available for this patient. This way it is not just one person making the decision but a moral community. Next, there will be a discussion about the benefits and burdens of each of the options. Then they will do the best they can to decide what should be done. They may have to make the difficult decisions about dying and death for this person.

The other option for the healthcare team is to have the court assign a public or private conservator or guardian for them. This court appointed person will make their medical and/or financial decisions for the patient. But of course, they don’t know anything about this person either so the choice they will make might be wrong.

My question for you is, “Would you want a stranger to be making life and death decisions for you?”

If the answer is no, then please tell your doctor who they should talk to if you are injured, write it down in your wallet and fill out your Advance Directive. I don’t want you to ever be the unbefriended patient.

Got a question? Ask Viki.

Why Won’t the Patient/Family Sign the DNR?

A couple of things may be going wrong. The first thing that happens is that the patient doesn’t understand the success rate of CPR.

On the television show “ER”, the patient not only survives CPR about 80% of the time but they also wake up with no negative consequences from the resuscitative efforts. We need to educate them that CPR works about 15-20% of the time on healthy people and less than 1% of the time for those with multi-system organ failure or metastatic cancer. We need to tell them that they may wake up in a worse condition than before and we need to tell them when it may only prolong their suffering and dying.

The second thing that goes wrong is that we limit our discussion to CPR. The CPR question should be one of many significant questions we ask during a meaningful end of life conversation. We need to ask them about how and where they would like to die.

Ask them, “How can I respect you and help you as you die?” We need to tell them that they have the choice of having a stranger straddling them doing compressions while their family waits outside the door or a peaceful death surrounded by their loved ones? I have never met a doctor who said they would choose the lonely CPR death, so why would you think your patients would want this?

The other thing most people want is to die at home but 53% die in hospitals and 24% in nursing homes. Please send people back home with hospice support.

One other thing you might try is you may want to begin using the term “AND” or Allow Natural Death when you talk about DNR. It is much easier to talk about what they would be allowing versus what you would be taking away from them. Just changing this language changes the discussion. This language also helps when you are talking to people from other cultures. It is difficult for families to choose to “give up” when what you are really offering is a good death.

No matter what, patients and families need us to talk about these scary and difficult subjects. We have to have courage to walk with them as they journey toward death.

Got a question? Ask Viki.

How Do You Want to Die?

Your doctor comes into the exam room or your hospital room and asks you, “Do you want us to do CPR?” (CPR meaning cardiopulmonary resuscitation or bringing you back to life after you have died or as some doctors brutally put it, “pounding on your chest.”) What would your answer be?

I’ve asked many groups of doctors, “How many of you would like to die by CPR?” And no doctor ever, ever raises their hand. What is it that they know that they’re not telling us? They know that the chance of CPR working is minimal, sometimes even 0%. But they don’t tell you this. They don’t tell you that it’s not like on the television show ER. On ER, CPR works about 80% of the time. In real life, if you’re healthy, CPR works about 15 to 20% of the time. And if you are close to death, CPR works less than 1% of the time and will prolong your suffering.

Now just to be clear, CPR does work well if you’re a fairly healthy person having a sudden heart attack. To illustrate this point, one hospital told me that it would be best if CPR was only done on visitors who dropped dead from a heart attack. Of course that was said as a joke, but the people in the hospital understood that there was some truth in it.

The other thing they don’t tell you is that it can be brutal. You may be brought back to life but in a worse condition than before both mentally and physically. Or that you and your family won’t have the opportunity for a peaceful and profound death experience. When you picture the last minutes of your life, do you see strangers straddling you on a bed, thumping on your chest, all alone, while your family waits outside the door? Or do you see a time with family and friends gathered around the bedside, perhaps with music being played or prayers being said or words of love being expressed?

I don’t know about you but I know what I want. I want a peaceful and dignified death.

A profound death is the choice you’re not being offered because the doctor is not asking you enough questions. Okay, they should ask you about CPR, just in case you’re one of the few lucky ones that will benefit, but there is more to be asked. They should also ask, “How can I respect you and help you as you die?”

But doctors don’t ask this. Why? Because they are afraid of death, because they care too much about you and they don’t want you to die, and because they don’t want to fail. I can understand that doctors have good reasons for not talking about death. Good reasons because they’re good people with caring hearts. But these reasons can get away in the way of us having the opportunity to determine how we want to die.

So what can we do? When the doctor says, “Would you want CPR?” give him your answer and then tell him that there are other things he should know about where and how you would want to die too. Now some doctors won’t even ask you the CPR question because they want to avoid the topic so you are going to have to begin the conversation. You’re going to have to teach the doctor to be brave and to be willing to talk with you. You’re going to have to ask for clear answers and for the support you need. And if you find your doctor won’t talk to you, find a different doctor who will. And if after talking with your doctor, you realize they don’t respect or support your choices, find a different doctor who will.

You deserve a good death.

Got a question? Ask Viki.

I Am in Pain, What Can I Do?

One of my hospice patients just called and said that his pain is at a 7 and he doesn’t know what to do. He saw his doctor and the doctor didn’t take care of his pain and said, “See you in two days.”

Are you kidding me? I would like to see this doctor stay at a pain level of 7 for 48 hours. The doctor wouldn’t put up with this if he was suffering and would make sure his own doctor took care of him. But he ignored my patient. When I hear about his happening, it makes me so angry.

Now I know, you must be thinking, “How can this be?” Well this happens a lot for many reasons. Let me tell you a few so you can know how to fix it.

1. The patient doesn’t speak up enough about the pain. If you don’t tell the doctor, how can he help you? If this is you or your loved one, do not leave the office until there is a new plan in place. And the plan should include a time limit for it to start working. If the new pain medicine hasn’t gotten your pain under control within a few doses, then you should call and tell the doctor and then he should adjust the plan.

2. The doctor doesn’t know how to take care of pain symptoms. Okay, now you are really surprised to think of a doctor that doesn’t know how to take care of pain. Well again, this happens all of the time. Most doctors can handle basic pain management but many are uncomfortable when they have to deal with the increasing pain that happens with cancer or other progressive diseases.

3. Maybe you are from a culture where you are encouraged to be brave and stoic about your pain. Now the doctor will end up misunderstanding about your pain and you won’t get the care you need. The doctor will ask you, “How is your pain on a scale of 1-10” or he will use the happy face chart. This works fine if you tell the truth about how much you are hurting but not if you don’t. So speak up and admit you are in pain.

4. Finally, and this will sound harsh but there are some doctors that don’t seem to care. If so, immediately get a new doctor. You should not go through your life in terrible pain and especially if you are dying. You should not have your final days be in pain. If you are dying and your pain is not being taken care of, then ask your doctor to put you on hospice. Hospice doctors and nurses are really good at taking care of pain and suffering.

Got a question? Ask Viki.

What is The K.I.N.D. Method?

The K.I.N.D. Method

K – Knowledge

I – Inquire and listen

N – Need to brainstorm

D – Decide and Do it

The Kind Method is a problem solving approach to making ethical medical decisions. The four step process is based on four core concepts: Knowledge, Inquire and Listen, Need to Brainstorm, and Decide and Do it.

The first step is Knowledge. If you don’t know enough information, you won’t be able to make a good decision. Patients make this mistake all the time when they don’t find out more about their disease and their medical options. Doctors also make this mistake when they don’t find out about the patient’s preferences and quality of life goals.

The second step is to Inquire and Listen. This is where most of us get stuck. We don’t ask enough questions. We don’t ask the right questions. And when people tell us the answers, we don’t listen well enough. Or we don’t like the answers and we refuse to listen. We need to ask better and to listen better.

Once you have collected enough information, then you can begin to figure out what you should do. Don’t just jump to the first thought that enters your mind. Instead do step three. You Need to Brainstorm to figure out your options. What is brainstorming? It is coming up with at least three different choices that you can consider. The choices may be as simple as: 1. Do what the doctor said, 2. Don’t do what the doctor said, or 3. Do only part of what the doctor said. Now that you have these three options, you can begin to seriously think about your choices and how each choice would affect your life. Think carefully because it is your life we are talking about.

Once you have done this, now it is time for step four. The fourth step is to Decide and Do it. At this point, the deciding may be easy but the doing may be more difficult. But if you have gone through the first three steps, you can feel more confident that you are making the right decision and it is time to take action.

Got a question? Ask Viki.