Emergency room doctor Tim Brown has experienced the anguish when someone arrives at the hospital and the doctors, nurses and paramedics put everything into saving their life, only to discover later that the patient would have preferred no extraordinary measures.
I’ve seen the frustration, said Brown, who also happens to be chairman of the Indiana House Ways and Means Committee. Especially with the EMTs. Once the ambulance gets there, they have to do everything.
The board-certified family physician, 57, said patients’ paperwork frequently doesn’t follow them when they are, for example, transferred from a nursing home to a hospital. And every entity has its own set of forms.
So, Brown, a Republican legislator since 1994, authored House Enrolled Act 1182, which goes into effect July 1. It requires the Indiana Department of Health to create a Physician Order for Scope of Treatment, or POST, form. The document will become the standard form used by all health care providers to communicate a terminally ill patient’s treatment preferences.
The law creates a single form that will be recognized by every health care provider – hospitals, nursing homes, emergency medical technicians and doctors’ offices. The form will also be more explicit, offering more guidance about patients’ wishes.
The movement for uniform physician orders for end-of-life treatment began in Oregon. According to the National POLST (physician orders for life-sustaining treatment) website, 16 states have similar laws, and a growing number of states are considering them.
Informing the public
Brown authored a similar bill in 2012, but it failed because of questions over language defining health care providers. This year the bill passed easily in both chambers of the General Assembly.
Proponents of the law, including the Indiana Patient Preference Coalition, which lobbied for it for two years, worry the lack of controversy means that the issue didn’t receive a lot of attention.
Because it went so quickly, most people in the state of Indiana are not aware of it, said Sister Carole Langhauser, a member of the coalition and former director of pastoral care at St. Joseph Hospital. (She left the hospital in May to take a leadership position at the Poor Handmaids of Jesus Christ Chapter House.) The average person needs to know, first, that there is such a thing and how it’s different from a do not resuscitate’ document or a living will document and who should have one, she said. Also, they need to know the importance of talking about this type of thing with your doctor and family.
Langhauser said the coalition is switching its focus from lobbying for the bill to educating the public about the law. Fort Wayne is one of the cities where the coalition is piloting its public information efforts.
What it is
It provides the possibility for patients to give nuanced notice of their preferences for care, said Abraham Schwab, a medical ethicist and philosophy professor at IPFW and a member of the coalition.
He said the new program will make it easier for doctors and nurses to comply with a patient’s wishes. It gives medical professionals more detail about the types of treatment a patient wants and, equally important, what life-prolonging treatments the patient wants to avoid.
Schwab said there are about six levels of care from which to choose on the form. For example, it includes orders on whether to resuscitate, give antibiotics or insert a feeding tube. It also lets the patient determine the duration of the treatment.
It’s a doctor’s order, signed, sealed and delivered for any venue that would accept a doctor’s order, Langhauser said.
Not only does it convey what type of medical treatment the patient wants, but it also carries the extra authority of a doctor’s order.
It indicates that a doctor has reviewed patient’s preferences and determined they are medically appropriate.
The standardized form – printed on bright paper to make it noticeable – will follow the patient throughout the health care system.
A POST order is similar to a living will or a DNR order, but it does not replace one.
Everyone needs to have those documents in place in case of an unexpected illness or injury, whereas a POST form is only for people with an advanced medical condition and who are facing the end of life.
It will take time, Brown said. A lot of people understand living wills and health care power of attorney and DNRs – you still need those. But when we don’t have any infirmities, you tend not to think about these issues. It will take some time for people to integrate this into their thinking. Physicians assistants, doctors, nurse practitioners need to have the conversation with their patients about the whole continuum of care.
Ethical thing to do
Langhauser worries some people will think having a POST that does not call for medical staff to do everything they can possibly do to prevent death is contrary to religious or moral teachings about respecting life.
But I think it’s a morally and ethically good thing, Langhauser said. If treatment is burdensome, they are not morally obligated to endure it. People on the whole sometimes think they are obligated to do everything they can do and to never give up.
She thinks there is a mindset among Americans that everything possible should be done to prolong life.
My personal philosophy is that just because we can do it doesn’t mean we should or always have to do it, she said.
Langhauser said the most important thing that this program will do is encourage families to have those difficult conversations about what kind of care they want if they become very sick.
At least have the conversation so that when the patient is at that stage, the order can be written so that it’s not a horrible thing. It’s not a surprise because you’ve already had that conversation.
The objective of the law is to ensure Hoosiers who are facing a life-ending illness are able to choose the specific medical treatments they want and that their wishes will be known and honored by all of the medical professionals providing them care.
The form will help those conversations between family members and between patients and their doctors, thanks to the physician-legislator whose professional experience informed his public service.