The Importance of Discussing End-of-Life Decisions

Many people have health care proxies, sometimes called advance directives, that authorize another person to make health care decisions for them once they are no longer able to do so.           How many, however, have actually discussed the difficult topic of end-of-life decisions with that person?  More often, this discussion is avoided until it is too late.  Health care proxies are often vague as to specific interventions or treatments that would or would not be agreeable to the person who is to be treated.          The Massachusetts Executive Office of Health and Human Services, in conjunction with the Executive Office of Elder Affairs, recently completed a pilot program in Worcester for a patient and doctor to discuss these issues and together create Medical Orders for Life-Sustaining Treatment (MOLST).           The MOLST, which is called Physician Orders for Life-Sustaining Treatment (POLST) in other states, is signed by both the patient and physician and outlines in detail whether the patient would choose certain end-of-life treatment.           The MOLST is meant to complement advance directives by providing more specific information about a person's preferences concerning treatment.  Some of the treatments specifically included on the form are do not resuscitate (DNR) orders, intubation and ventilation, artificial nutrition and hydration, palliative care, and the use of antibiotics.              Because the form is signed by both the patient and the physician, it allows the patient to express his or her wishes through actionable medical orders.  The form clarifies a patient's wishes and preferences as to these difficult decisions.           The orders must be honored as medical orders, as they are already signed by a physician. The forms become part of the patient's permanent medical file.           POLST programs are currently in effect in 14 states and 16 more are in the process of developing programs.             In March, the Massachusetts Expert Panel on End of Life Care issued a report entitled The Urgency of Health Care System Reforms to Ensure Respect for Patients' Wishes and Accountability for Excellence in Care.  The report was intended to review the current state of end of life health care and ways to improve the status quo.  Its recommendations, among other things,  include an increase in efforts to elicit and document patients' end-of-life preferences and an increase in coverage for hospice services.           The report also makes specific policy recommendations concerning the implementation of the MOLST model in Massachusetts, with a target date of full statewide implementation no later than January 1, 2014.            Regardless of whether or when this occurs, it is very important for each of us to discuss our values and wishes concerning treatment preferences with our loved ones, our health care givers, as well as our health care providers so that they understand our wishes.  It can be an uncomfortable discussion, but it can really help make a difficult time a lot easier.         Let us know if you have any questions or comments.