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    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.    


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