Polst: What It Is And What It Is Not: Fill & Download for Free

Don't get me started. When I was an admit nurse, I was shocked at the number of people who were upset, angry, refused to fill out a simple POLST form. The reason? They have never even considered the possibility that their 90 something mother would die.To even speak of the possibility of her heart stopping was tantamount to abuse. Who the hell do I think I am asking what to do if her heart stops?! Of course you give her CPR! My mom's going to get up and walk out of here!Unrealistic expectations is so common now, we actually report that in discussions with our medical director, the hospital, and hospice. It lets us know that the resident is at high risk for having a distressful, painful death. Everyone goes into high gear.I've had people feed unconscious relatives, try to get actively dying people out of bed to do “therapy”, refuse hospice until hours before death, and sue the facility because their parent died. Who cares that they were 100 years old and had multiple comorbidities, we LET them die!My favorite are family members who refuse narcotics to their parent with stage 4 cancer or had a motor vehicle accident. They don't want them getting addicted to narcotics.But denial is not for family members only, patients can get that way too. Not as many however, and usually they are helped along by family members.I do not like the term “fight cancer.” I loathe the phrase “lost the battle to cancer.” That robs the person of their dignity in my opinion. They are not a loser because they died of cancer. It is not a failure to die.Death is part of life. Most young people who view death with fear and anxiety do not realize that most older people who are dying are actually okay with that. They had a good life, but now they are old, and have chronic, possibly painful conditions. They have lost many loved ones at this point.Their children are possibly grandparents at this point. A great big circle of life is complete.Medical science can keep people alive for a much longer period of time. But not forever.

As an ER doc, I have been in this situation a few times. As a few others have noted, this situation is not about implied consent in an unconscious patient - it assume the patient is awake & able to coherently express that they do not want treatment.It’s important to remember that a patient always has the right to refuse anything, and that forcing treatment on them might be prosecutable.My approach varies, with the first consideration being the time sensitivity of what they are refusing - if it’s an immediately life-threatening problem, there may not be time for a prolonged discussion. Sometimes such cases progress so quickly that the patient becomes unresponsive and is no longer capable of refusing. If there is time, I need to very quickly assess “capacity” - is this a decision the patient is capable of making? Does he or she understand the consequences of this decision? If the patient has capacity, then they can refuse care and they may well die as a result of that. For example, I once had an elderly woman, just shy of 90, brought in by her husband after collapsing during dinner. Her aorta had ruptured and she was dying from it. Emergency surgery was needed - but she didn’t want it. She understood that it meant certain death, and she (and her husband) were OK with that. We did what we could to keep her comfortable and she died holding her husband’s hand… which was probably a better way to go than being rushed to the operating room and probably dying on the table with doctors and nurses performing CPR and doing “everything possible” to get her back…. where “getting her back” probably means anoxic brain injury, never getting off the ventilator, and dying of pneumonia in the ICU 2 weeks later having never really “woken up” after surgery. (This is sort of the whole point of hospice for patients with a terminal disease - quality of life takes precendence, and that may mean forgoing life-prolonging interventions. Indeed, even advance directives/POLSTs/DNR orders fall into this category - you decide ahead of time what you do/don’t want in terms of interventions in a life-threatening situation. It’s OK to say you don’t want life-saving interventions. Many in health care feel similarly after seeing what end-of-life in an ICU looks like.)Assessing capacity can be tricky, though. Once, a patient had been in a terrible motor vehicle collision that involved a diesel tanker truck. The patient’s car had rolled over multiple times but he did not seem that injured. However, his face and hands had been badly burned in the result fire. There were signs of burns inside the mouth, and I was worried that his airway would swell shut as a result of that. I wanted to put in a breathing tube. He refused. He told me he understood that this meant he might die - but he felt certain that his throat would not swell shut and he’d be OK. “That’s not going to happen.” I decided to proceed anyway - when the airway swells shut in a case like that, it can happen very quickly, and it can be nearly impossible to pass a breathing tube once that happens. I didn’t know if the patient had a head injury as a result of the accident, which may have clouded his judgement. He admitted to having “2 beers” prior to driving - and although he didn’t seem drunk, that may also have clouded his judgement. I decided to act in what I thought was the patient’s best interest. He had an IV in, and I told the nurse to give him medications to put him to sleep and then I put in a breathing tube. He ultimately did OK (and didn’t sue me…).When there is a bit more time, I usually start by asking why the patient doesn’t want the intervention we’re proposing. I have been surprised by how effective the ensuing negotiation can be. Sometimes people are scared. Or don’t really understand what it is we want to do. A few minutes spent educating a patient can work wonders. And I can often come up with some sort of workaround if I take the time to better understand why a patient doesn’t want something, what their concerns/desires are - there are usually many different ways to solve a problem in medicine and we can usually find something that the patient would be OK with.I also find girlfriends/wives (and sometimes ex’s) to be quite helpful in persuading a patient that they really do need that intervention.It’s also amazing how ornery a smoker can get when they really need a smoke… and how, after a cigarette, they are much more amenable to antibiotics or surgery or whatever intervention they might need.

That a lot of people have reached an advanced age without thinking, planning, heck, even considering the fact that they are going to die. It's a taboo subject.This is passed down to their family members who become anywhere from irritated to enraged that they need to fill out a simple POLST form, which is the one for DNR/CPR, tube feeding, and so on.I mean, how DARE we even think that their 98 year old mother with advanced COPD, CHF, and stage 4 kidney disease who just fell and broke her hip might have a cardiac or respiratory event! The nerve!And don't even mention hospice. My mother is going to get up and walk out of here! It’s delusional. I've seen people trying to shovel food in the mouths of people who are actively dying. They yell at them to keep trying, don't give up.They are dying. It is not a failure to die. We all will journey there someday. But denial can make what should be a family bonding time into a nightmare.