Journal of Clinical Ethics Recognizes Advantages of POST Over Advance Directives: West Virginia Touted for Its Successful Program
In the most recent issue, the Journal of Clinical Ethics published a Legal Briefing on POLST: Physician Orders for Life Sustaining Treatment. The authors, Thaddeus Mason Pope, JD, PhD Director of the Health Law Institute and Associate Professor of Law at Hamline University School of Law, Saint Paul, Minnesota and Melinda Hexum, MS, second-year law student and Associate Editor of the Hamline Law Review, noted that there are at least fourteen different names for similar forms used throughout the United States. Originally called Physician Orders for Life-Sustaining Treatment (POLST) in Oregon, there are many different acronyms including MOLST (Medical Orders for Life-Sustaining Treatment) and four other acronyms based on scope of treatment rather than on life-sustaining treatment. Idaho, Indiana, South Carolina, Tennessee, and Virginia call their form POST as does West Virginia. Louisiana calls their form La POST and Alaska, Colorado, Kentucky, New Mexico, and North Carolina call their form MOST (Medical Orders for Scope of Treatment). The authors regard POST programs as a “national phenomenon.” As of September 2012, at least 46 states or communities had a POST program of some form. The authors note that advance directives have had limited success. They recognize several advantages of POST forms over advance directives.
- It is signed by a healthcare provider. There is no need for interpretation and translation. It is an immediately actionable medical order.
- It is easy to follow because it is on a single-page, standardized form.
- Unlike Do Not Resuscitate (DNR) orders, POST addresses not just CPR but an entire range of life- sustaining interventions.
- POST is transportable. It is a brightly colored clearly identifiable form that remains in the patient’s chart and travels with the patient from hospital to nursing home to ambulance to the patient’s home.
The authors also note that POST protects and promotes patient autonomy better than advance directives in four ways.
- POST is created with a healthcare provider at or near the time when an acute or serious condition develops. POST has a greater chance of being more informative, more relevant to the specific medical situation at hand.
- Since the form is highly visible, portable, and travels with the patient’s medical records it is more likely to be available when a decision must be made.
- Since it is written in precise medical language, it is better understood.
- Since it is signed by a health care provider, it has a greater chance of compliance by other providers.
The authors observe that POST is more than a form; it is a tool providing a framework for end-of-life care conversations between patients, families, and healthcare providers. Providers are encouraged to discuss specific scenarios and treatment options. Patients and families have the chance to ask questions and make their wishes known. In short, it gives patients more control of their end-of-life care. With POST, “healthcare providers know immediately what patients do and do not want, and they can provide treatment and care consistent with these preferences.”
West Virginia recognized
The authors identify four states as having particularly better established POST programs: West Virginia, Oregon, New York, and California. They observe that in these four states the POST form and program have achieved broad clinical acceptance; use of POST is particularly well documented in West Virginia and Oregon since investigators in both states have published research reporting the vast majority of nursing facilities and hospices in the states use the POST form. These states have also ensured the sustainability and refinement of their programs through the maintenance of effective statewide and local coalitions and through obtaining significant financial support.
In a section in the article on statutory recognition of POST, West Virginia is cited as an example of a state whose laws provide more detail regarding the POST form but with enough leeway to allow the form to evolve without amending state law.
In the section in the article on electronic registries, West Virginia and Idaho are commended for having state registries that contain not only POST documents but also advance directives and other healthcare documents. At the end of the review on POST forms, the authors conclude:
“POST helps patients. It documents a patient’s wishes for life-sustaining treatment in the form of a medical order. It streamlines the transfer of patient records between facilities. It clarifies treatment intentions and minimizes confusion about patient preferences. It assists physicians, nurses, emergency personnel, and health care facilities in promoting patient autonomy. It optimizes comfort care of patients.”
The authors also observe that POST programs are driving other healthcare-related reforms. Most notably is greater attention to advance care planning. Because the POST form requires the patient to express his or her preferences with regard to not only CPR but also a desired level of medical intervention, completion of the POST form is promoting conversations which are helpful to patients and families to ensure the patient’s wishes are respected and families are not burdened with making decisions unaware of their loved one’s wishes.
It is gratifying to see the recognition by The Journal of Clinical Ethics of the advantages of the POST program and to see that West Virginia identified as one of the leading states in this national phenomenon!
Thaddeus Mason Pope and Melinda Hexum, “Legal Briefing: POLST: Physician Orders for Life-Sustaining Treatment,” The Journal of Clinical Ethics 23, no. 4 (Winter 2012): 353-76.
WV e-Directive Registry