Taking the time to get it right on end-of-life care wishes
By Barbara Peters Smith, Herald-Tribune
Monday, November 21, 2011
BOSTON – "There are a lot of people in Florida who are very mad at me," said Marshall B. Kapp, director of the Florida State University Center for Innovative Collaboration in Medicine and Law. He is the guy in charge of the state's initiative to adopt a policy for the POLST – short for Physician Order for Life-Sustaining Treatment.
Some 14 states now have some form of the POLST, which goes a step beyond advance directives to provide very specific guidance about the kind of medical treatment a patient wants to receive near the end of life, from emergency resuscitation to ventilator care. Kapp said he has heard from people who don't understand why Florida is taking so long to join the trend.
The idea behind Polst is that some health care providers are unwilling or unable to respect what patients have spelled out in their advance directives for care, sometimes because the language is too vague to apply to the situation at hand, or the paperwork gets lost in the shuffle of emergency treatment. The POLST, usually signed by a physician and the patient, represents their agreement after a conversation about possible health scenarios and has been shown to carry more weight in a hospital setting.
Some patient advocates object to the POLST because it underscores the power that physicians hold in the system, Kapp said. "That's right," he added, "but I think we need to adapt to that reality."
He describes Florida as "in the developmental stage," and said he has just begun talks with the Department of Health on how the practice can be implemented. He hopes it will a question of months, not years, but is willing to wait to get the technicalities right.
"A lot of people think that once there's consensus on the concept, you can have it in place," he said. "But there are a lot of issues that need to be dealt with once the concept is accepted."
Among these issues:
– Patients' rights to make decisions about their care, or have a proxy do it for them, are already supported by Florida statutes. But should there be legislation or regulation that makes the POLST easier to enforce?
– Should physicians be legally required to offer the POLST to patients? Who can sign the form, other than a physician?
– Should a POLST from another state be recognized in Florida? What if a patient's POLST and advance directives are in conflict?
– What should be the penalty for a health care provider who does not respect the POLST?
Kapp was speaking at a symposium on end-of-life care at the annual meeting of the Gerontological Society of America. Kathy Black, a professor of social work at the University of South Florida, Sarasota-Manatee, gave a talk at the same session on the national movement to encourage people to have written instructions in place for health care providers. Black pointed out that most people fail to consider the possibility that they will be unable to control their care when the time comes.
"We know the majority of people will have years of functional cognitive decline before dying," she said. "In the intensive care unit, 95 percent of people lose capacity to make decisions for themselves."