On July 1, 2013, Indiana passed into law a new type of advanced health directive form called Physicians Order for Scope of Treatment (POST). After reading this first line, I’m sure most of you have hit the back browser onto the next article. I don’t blame you. Contemplating one’s end of life wishes is not exactly a light or pleasant topic of discussion, but somewhere in the back of our brain each of us has a checklist line item to discuss our future health care choices in the event something tragic would happen. Indiana law now specifies four advance directive forms: Life Prolonging Procedures Declaration, Living Will Declaration, Out-of-hospital Do Not Resuscitate Declaration and Order, and Physicians Order for Scope of Treatment. All four forms reinforce a patient’s health care wishes with different levels of details and become more appropriate at different stages of an illness. The POST form was brought to Indiana by the Indiana Patient Preferences Coalition (IPPC) back in August 2010. This group of professionals from health care, ethics, law, and senior services desired to add Indiana to the growing list of states adopting the POLST paradigm (www.polst.org). After successfully establishing the Indiana POST program, the big hurdle now is educating doctors, patients, and the community on the existence and use of the form (www.indianapost.org).
Reading through the Indiana POST website, the form targets elderly patients and those with a serious illness, who have likely started having end-of-life discussions with their doctor. The intent of the POST form is for the patient and their doctor to discuss what the patient desires in regards to CPR, the desired level of medical intervention, antibiotics, and artificially administered nutrition. The POST form provides a more detailed scope of care than the other advanced directives. After the doctor signs the two page POST form, it becomes a transportable order set the patient carries across any health care setting. So, regardless of your place in the health care system (at home, nursing home, in the ambulance, in the ER, admitted to the hospital), the POST form can be honored by all providers. This is not the case for most other advanced directives, which leave muddy ethical waters for physicians and family members to wade through in the event of an emergency. Take for example the Out-of-Hospital Do Not Resuscitate form often used in nursing homes. When filled out, this would dictate no CPR be performed if the patient’s heart were to stop outside of the hospital. But, what if the patient's heart stops in the hospital? What if it stops in the ambulance on the way to the hospital? What if it stops in the ER immediately upon arrival to the hospital? In my experience, the folks who did not want the aggressive treatment outside the hospital do not want it in the hospital either. This dilemma is one of many the POST form helps to fix as the signed set of orders is recognized at every level of care the patient comes into contact.
So what do doctors think about this? I asked Dr. Lindsay Weaver, Assistant Professor of Clinical Emergency Medicine at Indiana University School of Medicine who is fellowship trained in palliative care, what benefits the POST form carries for a patient. Dr. Weaver states:
“As an emergency medicine physician, the POST form is the most informative advance directive that I can take action on in the emergency department. It describes a patient's end of life wishes in medical terms that both patients and physicians can understand. Also, since it is a physician's order, prehospital providers [such as EMTs] can also follow the form's directives. Unfortunately, Living Wills only apply to a particular condition of a patient and therefore do not help emergency physicians in most cases.”
The tricky ethics around the POST form (and all advanced directives for that matter) do not go unnoticed as end of life issues are full of hard decisions. Some are wary of this as a permanent document in their medical file, however, like any written advanced directive, the discussion with their clinician should be fluid. Changes are easily made to be in line with the patient’s desired wishes for end of life care. Whenever she sees a patient with a life limiting illness, Dr. Weaver uses a patient’s POST form as a conversation starter with the patient and family. Per Dr. Weaver, “I go over the form with the patient and family and discuss with them what is available to be done and what are my recommendations. If the patient is not able to speak for themselves, for example, because they are too sick, I show the family that by filling out the POST form their loved one helped direct decisions by documenting what is most important to the patient at the end of life.”
If such a form may benefit you or a family member with a serious illness, you can bring up with your primary care doctor. If you are stuck at any point during the process of getting a POST form in place, a KayBee volunteer is available. You can obtain more information and a downloadable copy of the form at the Indiana POST program website (www.indianapost.org) and the Indiana State Department of Health (http://www.in.gov/isdh/25880.htm). The websites recommend printing the POST form on bright pink cardstock. The health care system is not perfect, but regarding end of life care, the POST form will help assist communicating your or your loved one’s wishes across the entire system of health care providers. Have more questions or not quite sure what next steps to take? Email email@example.com