Mathew D. Pauley, JD
Mathew D. Pauley, JD, is a clinical ethicist for Kaiser Permanente Northern California, where he provides support and guidance to hospitals regarding ethical decision-making and conflict resolution, Oakland, California. KP.org
Nearly 40% of older Americans have some form of advance directives, such as a living will to communicate wishes about life-saving treatment…or a medical power of attorney appointing a loved one as proxy if they’re incapacitated.
Problem: Your wishes may not always be followed in real-world situations. Examples: Emergency paramedics typically provide CPR to restart a patient’s heart even if that patient’s living will says otherwise. And complex medical circumstances at the end of life often arise that force your loved ones to make judgment calls about what you really want.
Bottom Line Personal spoke to clinical ethicist Mathew Pauley about how to make sure hospitals, medical providers and family members follow your medical wishes…
If CPR is not in line with what you want, ask him/her to fill out a Physician Orders for Life-Sustaining Treatment (POLST) form. This medical order provided by the states gives you greater control over end-of-life care during emergencies. It outlines very specific preferences for treatments that you do and do not want to receive including CPR and defibrillation…intubation and ventilation…and administration of nutrition, fluids and antibiotics. If you are very sick or frail, these treatments may save you but also could cause irreparable damage—that harm needs to be compared to the potential benefit and the patient’s goals for care.
Why you need a POLST form—even if you have an advanced directive: Without a POLST form, paramedics (and other first responders) are obligated to resuscitate you and transport you to a hospital. Emergency department doctors may take aggressive life-saving measures because your living will is not available or specific enough.
Best: Post a copy of your POLST form on the refrigerator in your home…keep a copy in your wallet…and make a digital screenshot and keep it on your smartphone. POLST forms vary from state to state. For more information: POLST.org/state-polst-programs.
Important: If you’re preparing for surgery, you may want to suspend your POLST form temporarily while you’re in the operating room in case your heart stops temporarily during the surgery.
One recent study found that proxies guessed wrong about what their loved ones would really have wanted in nearly one out of three simulated end-of-life situations. That’s because many elderly patients leave vague or conflicting advanced directives. Example: You say, “I want full treatment to save my life”…but also, “I never want to be in a vegetative state.”
If death is a taboo subject in your family, you may avoid discussing the rationale behind your wishes. How to start these deeper conversations with your proxy: Give information that could help loved ones interpret your wishes in unforeseen situations. Talk about what scares you the most about the end of life…what makes life worth living for you…and how and when you would want it to end.
Check that the forms have been included in your electronic patient health records since information isn’t always shared among facilities and providers.
