Human Exceptionalism

POLST’s Potential for Abuse

With the growing technocracy in medicine, it becomes increasingly difficult for patients to have actual control over their own care. Everything has become so (expletive deleted) arcane! Mind numbing, which is very dangerous because there is great potential for abuse in them-thar hills.

Take the POLST, which stands for Physician Order for Life Sustaining Treatment. This is a document placed in the patient’s chart that directs the medical team how to care for a patient in the event of a life-threatening circumstance.

POLST is different from an advance directive, such as the durable power of attorney for health care. But it is supposed to reflect patient or surrogate desires, and thus, be consistent with the AD. But if the POLST contradicts the AD, its instructions may be carried out instead of what a patient directed in his or her AD.

POLSTs follow the patient if he or she changes care/treating institutions. That means a mistake made in hospital A follows the patient to nursing home B.

POLST forms do not expire, and thus they can bind a patient years after signing, even if they no longer reflect patient desires.

California Advocates for Nursing Home Reform has published an important white paper that should be pondered by anyone with a loved on in a nursing home or hospital. Since I think these findings may not be exclusive to California, I share a few highlights with you here:

1. Virtually anyone (in CA) can sign a POLST form–it doesn’t necessarily have to be the patient, closest family member, or appointed surrogate. The potential for abuse is obvious.

2.The (CA) law does not require POLST orders to be compared with a patient’s advance directive to assure they are consistent. That means a POLST order could require care a patient does not want, or more likely, visa versa.

3.POLSTs are not mandatory, but 73% of patients were often or always told that they are, and apparently, there are reports of manipulation of patient “choices.”

4. Non-health care professionals often fill out the POLST forms contrary to law. That’s a problem:

In long-term care facilities, a staggering 57% of all POLSTs are believed to be completed by non-health care professionals such as admission coordinators and business managers. While these persons may possess some basic knowledge of health care, they are not experts in medicine and the issues of end-of-life care. Thus, many important choices on the form and their implications may be inaccurately explained or not explained at all, leading to violations of patients’ basic rights to give informed consent prior to medical treatment.

5. This part is also really scary: Apparently POLST orders have been signed by family members even though the patient was competent! 

One Long-term Care Ombudsman in Los Angeles reports that multiple nursing homes have a standard practice of having POLSTs signed by resident family members, regardless of whether the resident has capacity to make health care decisions. This observation is reinforced by the fact that 59% of surveyed Ombudsman found that POLSTs were signed by third parties, even when the resident had capacity, “often” or “sometimes.”

Think of a family member whose potential inheritance is being drained by the costs of care. Or, a family member with a different good faith perspective than the patient. If they sign a POLST, their views– instead of the patient’s–will be followed.

I know this is eye-glazing but attention must be paid!

I was the named health care surrogate for my late aunt. I was offered a POLST to sign–and did. But I required that I be called before life-impacting decisions were made in almost all circumstances–DNR excepted, per her expressed AD wishes. In that way, I retained control to react to actual circumstances. That approach worked out very well for my aunt as she was dying.

Just a suggestion, but if you are a surrogate and asked to sign a POLST, you consider doing likewise. The life you save may be that of someone you love.

For more information on POLSTs than I can give here, see this fact sheet from the always elucidating Patients Rights Council.


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