Chronic Pain and Physicians Orders for Life-Sustaining Treatment
The end of life can be riddled with pain and suffering. In order to assist those with a serious medical condition in making their wishes known, California's Governor just signed a new law (effective January 1st, 2009) that legalizes the Physicians Orders for Life-Sustaining Treatment (POLST). Other states have already instated the POLST and each state's status can be viewed at the POLST website, www.polst.org.
Imagine that you are 87 years-old with serious cardiac and respiratory diseases. Would you want to be revived if you suddenly stopped breathing? Would you want antibiotics if you got an infection? How about intravenous (IV) fluids or a feeding tube? The POLST form helps you, your loved ones, and your health care providers discuss these critical questions and develop a plan. With a plan in place, your wishes will be known and respected by others. The POLST form is broken down into four main parts: Resuscitation, Medical Interventions, Antibiotics, and Artificially Administered Nutrition.
Resuscitation: Resuscitation, also known as CPR, is done in the event that a person stops breathing or the heart stops beating. The forceful pressure on the chest can lead to painful broken ribs and punctured lungs. If a person is revived, there may be resulting brain damage and the quality of life may not be the same as before he/she stopped breathing or the heart stopped beating. If a person is revived, he/she may be on a breathing machine (mechanical ventilation) with a tube down the throat. Resuscitation does prolong lives. However, one with a serious medical condition may wish to decline the option for being revived because he/she may want to avoid further pain and suffering.
Medical Interventions: A critically ill person may also wish to have comfort care only. This order will keep the medical personnel focused on keeping the person comfortable instead of focused on medical procedures that may prolong life. Pain control is the main priority with comfort care. Wound care, bowel care, and bladder control also qualify as interventions that enhance comfort. Other additional treatments can be added to have a tailored plan for one's desired wishes.
Antibiotics: Antibiotics fight infections. On the other hand, antibiotics can also prolong death in a person who is terminally ill and this may also prolong suffering. Pneumonia used to be considered "old man's best friend" for a reason. Sometimes infection is the quickest, most painless way to die. One with a serious medical condition needs to make his/her wishes very clear when it comes to treatment with antibiotics. The POLST form will help to formulate these plans.
Artificially Administered Nutrition: Feeding tubes are very controversial near the end of life. When someone loses the ability to eat or drink, fluid and nutrients can be given by a tube that is inserted thru the nose and into the stomach (NG tube) or by a tube inserted directly through the skin into the stomach. Feeding tubes can cause ulcers and infections. Because NG tubes are very uncomfortable, agitated patients usually try to pull them out. The nutrition can be life-sustaining, but that may not be what a seriously ill patient wants. When the end of life is near, the exact wishes regarding artificially administered nutrition need to be clearly outlined and discussed by the patient, the family and health care team.
Summary: As a physician and a family member, I have seen healthcare go astray from the primary goal of treating suffering, which is especially important at the end of life. Death does not have to be a painful, agonizing process. The treatment goals need to be clearly defined and discussed. This new tool called the Physicians Orders for Life-Sustaining Treatment (POLST) is a simple to use document that clearly makes the individual's wishes known to doctors, nurses, emergency personnel, and other healthcare staff. Talking about these treatment choices is emotionally difficult. But, witnessing pointless pain and suffering at the end of life is even more heart wrenching. Make your wishes known!