[This article has been edited lightly since publication.]
People agree to things too easily in pressured settings. During the front-desk formalities at an emergency room, for example, it can almost seem foolish to insist on reading and understanding every paper before signing it.
This is a major reason why estate planners urge people to prepare advance written instructions for medical care in case of emergency or incapacity. An important function of an Advance Health Care Directive is to protect its creator from having to make important, potentially life-ending decisions in unfamiliar settings with pressure from people in official roles.
However, some concern now exists that, if a real crisis hits a patient, a typical Advance Health Care Directive may not be clear enough. For example, paramedics arriving at a house might not understand whether to start CPR, or a junior nurse in a hospital might not know whether to give antibiotics or place an IV line.
To answer this concern, the California legislature has developed simpler, clearer, grimmer documents known as "Requests Regarding Resuscitative Measures." The oldest document of this type is the simple “Do Not Resuscitate” or DNR order. As of January 2009 the Legislature added the POLST, or “Physician Orders for Life-Sustaining Treatment”. It is now addressed in the California Probate Code provisions beginning with Section 4780.
POLSTs and DNRs can be helpful in enforcing a seriously ill patient's wishes, especially for someone who wants to die at home without the physical violence of CPR or the bureaucracy and disruption of an ambulance to the hospital. However, these are documents with potentially drastic effects that should be approached with care. Particularly, they should be viewed with caution if patients are invited to sign them during admissions to hospitals or nursing homes. In such contexts, people could literally sign away their lives without knowing it.
Between the two kinds of resuscitation forms, a DNR form seems less likely to be signed by accident: it's a simple form, and the words "Do Not Resuscitate" are clear. But sometimes patients have been pressured unjustly to sign DNR forms in congregate sites such as nursing homes or other institutions. Patients are not ever required to sign these potentially life-ending forms. It is important to think carefully before signing any such form, even in an emergency situation. You always have a right to refuse.
A POLST, on the other hand, is at an awkward middle level of complexity: it’s detailed enough to confuse a patient about its possible meaning, yet so clear in its instructions to a trained medical technician that it might be obeyed without second-guessing.
So it's especially scary to think that a POLST might be included in a mind-numbing stack of paperwork to be signed in a situation like a nursing home admission, where patients may feel afraid or socially awkward about asserting their real wishes, or where they may lack sufficient information or opportunity to ask questions about the authority that a POLST carries.
It may be a good idea for some people to sign a POLST to describe specific types of care that they do or do not want, but here are things to know about POLSTs before agreeing to them:
People shouldn't reject "life support" in general before understanding that many kinds of routine care fit under that description. In popular culture, "life support" is sometimes thought of as dramatic, invasive, possibly painful or life-threatening in itself – for example, CPR, or a ventilator, or systems used to keep a body alive after cognitive function is lost. So people may think of “life support” as heroic measures to be taken (or not) when there's little real hope for recovery. In fact 'life support’ addressed by a POLST can include many kinds of ordinary care. For example, a POLST can allow or prohibit include not only the dramatic interventions, but also simple temporary emergency care for a person who is likely to recover well – perhaps antibiotics, emergency steps to clear a patient's airway, or a temporary IV line to feed and hydrate a patient recovering from a crisis.
A POLST is a mortally important document, not an afterthought. A POLST can be obeyed without any requirement for the doctor or the agent holding power of attorney to be present. Emergency medical responders are trained to look for a POLST. The state standard recommends printing it on attention-getting heavy pink paper, and good practice calls for it to be placed prominently in a patient's medical file, or in an obvious spot at home like the refrigerator door. It is not the same as an Advance Health Care Directive, but it is meant to supplement one and can override one if it was signed more recently. It has some things in common with a DNR form but it covers more kinds of detail than the DNR. POLSTs are typically recommended when a patient becomes ill enough to face decisions about specific life-extending procedures such as the use of feeding tubes or respirators.
If a POLST or DNR gives an instruction that conflicts with an instruction in an Advance Health Care Directive, the instruction that was signed more recently must be followed under Probate Code Sec. 4781.4. This is true no matter how much time the patient spent thinking about each of the documents. You may have spent several evenings at home choosing language for an advance health care directive, but if you sign a POLST in a hospital waiting room on the morning you go in for surgery, then the POLST is what the medical team will obey first if something goes seriously wrong.
Two people sign a POLST. One is either the patient or the person acting as the patient's health care agent under a Durable Power of Attorney for Health Care. The other person to sign is the patient's doctor — or a nurse practitioner or a physician assistant acting under the supervision of the physician. The doctor's involvement is one reason for worry about people signing POLSTs too easily: doctors are so respected that they may be obeyed even if they don't interpret a patient's stated wishes correctly. Be sure the doctor or other medical professional writes down what you really want. The possibility of involving a health care agent is another reason for worry: the health care agent might also interpret or "remember" the patient's wishes wrong. If you choose the option in an Advance Health Care Directive to give your health care agent immediate authority, then your agent can sign a POLST on your behalf even if you have capacity to make your own health care decisions. If a POLST is signed at all, it is better for you to sign your own POLST with a doctor you trust, while your head is clear and there is no emergency or other pressure hanging over you.
Sometimes people may be asked to sign new durable powers of attorney for health care on forms provided upon arrival at hospitals or skilled nursing facilities, even if they have already signed more detailed and carefully edited documents with their own lawyer. If new POLSTs are placed in front of people in such circumstances they may be persuaded to agree to choices that they don't feel they are given the time to think through. It is a good idea to execute an Advance Health Care Directive even if you also have a POLST. It is helpful to appoint an agent to make health care decisions. Advance Health Care Directives do that but POLSTs don't.
Electronic copies of POLSTs are available for download from the Coalition for Compassionate Care of California, in English, Spanish, Chinese and several other languages. (If you print your own POLST, buy some “Ultra Pink” paper from a stationery store to print it on. Emergency staff will look for this bright pink paper.)
POLST and DNR forms are both available from the California Emergency Medical Services Authority.
In other words, the basic rules of dealing with life-altering paperwork apply doubly to POLSTs and DNRs: read everything before deciding whether to sign it, and don’t sign if you feel pressured, ill, or uncertain. A POLST may be helpful at some time in your life, but if you choose to fill out and sign one with your doctor or other medical professional, you should take time to understand the form fully and make sure the decisions it expresses are entirely yours.