POLST Paradigm Initiative Reaches from Oregon to NC

June 22, 2006

As we reported in March, Oregon's end-of-life orders document — "POLST"— is being proposed in a number of states across the US. In North Carolina, the form has undergone pilot tests, and the North Carolina Medical Society is considering its adoption.

The purpose of this letter is to

• Review the history of POLST on a national level
• Update you on the status of North Carolina's version of POLST

POLST: the ultimate pink slip

POLST is an end-of-life orders document. It is a form — along with a coaching process — to convert advance directives into physician's orders as a patient's condition changes. POLST was devised in Oregon in the 1990s under grants from the Greenwall Foundation and Cummings Foundation,[1] frequent sponsors of right-to-die organizations.

The POLST Task Force emphasizes that the POLST form is not an advance directive, which means that in Oregon — and many other states — it is not bound by state advance directive statutes which often require the patient's signature.[2]

Assisted-suicide proponent Ann Jackson testified before a Senate subcommittee this past May on the success of the Oregon Death with Dignity Act. In the course of her testimony, she said that one of Oregon's successes was POLST. According to Jackson, "respect for end-of-life wishes is virtually 100% when POLST...is in place." [3]

No wonder there is 100% compliance with POLST.  POLST forms are typically written as the patient's condition changes; frequently they are written when the patient and/or his agent are under duress. So, for example, as a patient is going into a crisis, an EMT or nurse or respiratory therapist might counsel the patient — or surrogate — on next steps with regard to accepting a feeding tube or respirator. POLST instantly converts these "wishes" into physician's orders. Naturally, the orders are usually followed. However, one wonders whether the same "wishes" would have been expressed by a more informed patient, counseled in less stressful circumstances.

According to the POLST website (www.polst.org), some form of POLST has been endorsed by the following states or regions: Oregon, Washington state, West Virginia, sections of NY, Wisconsin, and Pennsylvania. The following states are developing programs: NH, MI, HI, NV, UT, NE, MO, TN, NC, GA, and FL. The forms may be implemented voluntarily through medical boards, and/or via direct legislation.

North Carolina's End-of-Life Orders document "MOST"

When we last wrote to you, the North Carolina end-of-life document was named POST (Physician's Orders for Scope of Treatment). The document has been reviewed, amended, and approved by the North Carolina Medical Society's Ethical and Judicial Affairs Committee. The document is scheduled to be returned to the Task Force, and there may be other reviews and changes in its future before implementation.

We have attached the newest version of the North Carolina document to this newsletter. The document's name, which was POST in March, has changed to "MOST" (Medical Orders for Scope of Treatment).  There are also a few other changes in addition to the name change. Next week we will post a full discussion of MOST on our website (www.lifetree.com). In the meantime, here are changes we've noted:

• The name has changed from POST to MOST (change from "Physician's orders" to "Medical Orders")
• Signature was "optional;" signature is now "preferred."  However, the form is "still effective without signature," and at that, the signature can be that of a "Person, Parent of Minor, Guardian, Health Care Agent, Spouse, or Other Personal Representative."
• Informed consent:  Statement to be signed by patient/proxy now begins "I agree that adequate information has been provided..." and ends with "This document . . . indicates informed consent."  (Q: Is the patient really as well informed as the boilerplate statement indicates?) 
• Where the POST form referred to "physician", the MOST form expands to "physician (MD/DO), physician assistant, or nurse practitioner." 

Bottom line, these forms are being tested across North Carolina.   LifeTree does not endorse the POLST program at all, and does not recommend the adoption of the MOST form. If it is really true that too many patients are being forced into life-saving technologies at the end of life, this form does not solve the problem. The form will often be completed under duress, without full information, and further corrodes communication between the primary physician and his or her patient.

Pro-life physicians should be made aware of what the NC Medical Society is trying to move into the system.

God bless you.

Betty and Ione

Elizabeth D. Wickham, PhD, Executive Director
Ione Whitlock, Chief Research Associate
LifeTree, Inc.

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Endnotes:
[1]  "History of POLST Paradigm Project" at POLST Paradigm website, maintained by the Center for Ethics in Health Care at the Oregon Health & Science University; also Recent Developments in Physician-Assisted Suicide, June, 1998, "Medical Developments," #10 at Willamette University's web site. 
[2] See "Information for Health Care Professionals" at the POLST Paradigm website; also,  S. Tolle, S. Hickman, J. Newman, The National POLST Paradigm Initiatve, page 4.  For a history of POLST in Oregon, and what to look for in other states, see  State Initiatives in End-of-Life Care, Issue 3, April 1999, "Implementing End-of-Life Treatment Preferences Across Clinical Settings."
[3] Testimony of Ann Jackson, MBA, Executive Director, Oregon Hospice Association, before the Senate Committee on Judiciary Subcommittee on the Constitution, Civil Rights, and Property Rights, “The Consequences of Legalized Assisted Suicide and Euthanasia”, Thursday, May 25, 2006.