Photo: Barbara Krawcowicz (flickr)
The Indiana legislature passed a bill this session establishing medical orders signed by a doctor that are aimed at creating consistency in the healthcare system for those approaching the end of life, whether from old age or disease.
In Indiana the form is called the Indiana Physician Orders for Scope of Treatment or POST, but the program exists in several states.
When Indianapolis resident Sandy Cath’s father passed away a few years ago, she used California’s version of POST. She says she was relieved he could ensure nothing would happen to him that he did not want.
“Should I say easier? It’s hard to say it’s easier but it is a gift to be able to not be ambiguous, to have it be clear what someone wants so that you can be sure you’re giving them what they want,” she says.
Cath remembers sitting down with her father and her siblings as he laid out exactly what his wishes were and how the form made them clear. And she says it is that clarity that is key.
“So that there’s no fighting and arguing amongst family members which can be a very destructive thing at this time,” she says. “And family needs to be support each other and it allows that to happen.”
Breaking Down End-Of-Life Decisions
IU School of Nursing professor Susan Hickman has been researching programs like POST for 15 years. She says, while forms similar to POST exist in some places in Indiana, it is a patchwork that does not transfer from one healthcare facility to the next.
“So you can have a beautiful conversation in a nursing facility, a really clear document that outlines what that person does and does not want and if they transfer back to the hospital, the hospital is unable to honor that,” she says.
That can be frustrating for patients, says Wishard Hospital’s Acute Elder Care Consult Service medical director Ella Bowman because the default standard for care in a hospital setting is to do everything medically possible to a patient.
“Some of them not only don’t want it but we know that aggressive care does not necessarily benefit somebody with a life-limiting disease or with many, many serious problems such as terminal cancer,” she says.
Bowman still makes house calls, dealing regularly with the very patients POST will help. The legislation will require POST to be recognized across the healthcare system, making sure patients’ wishes are followed no matter where they are cared for.
Bowman says the beauty of the program is that it is easy for both medical professionals and patients to understand. The form is essentially a checklist, allowing a person to choose, for example, whether they want antibiotics only for comfort or if they want to decline a breathing or feeding tube.
Bowman says POST allows doctors and patients to make those decisions under the best possible circumstances as opposed to when they typically take place.
“Often that comes down to dealing with a very terrified person in the middle of the night, asking them, ‘Well, if your heart stops do you want us to try to restart it,” Bowman says. “If you stop breathing, do you want us to put you on a machine to make you breathe?’”
POST Could Encourage Difficult Discussions
As Bowman and Hickman point out, POST is for their families in addition to patients, because it is often family members who have to make the decisions POST includes. They say the program will hopefully generate a conversation that both doctors and patients avoid.
“We really do have a lack in our society of reality,” says Franciscan St. Francis Health Palliative Care Medical Director Jerry Walthall. ”We don’t deal with death and dying at all. We act like it’s an elective and it is not. It’s a required course for graduation unfortunately.”
Bowman says, even as a doctor working in geriatrics and palliative care her whole career, she never had the conversation with her mother.
“So when it came time to, oh her kidneys are dying, would she have wanted dialysis? I don’t know, Mom never told me. Would she have wanted a transfusion? I don’t know, she never told me,” she says.
Hickman says patients and family members can also bring the form to their doctor to use. She notes it will take years for the program to be fully implemented statewide.
Implementation will begin primarily in Indianapolis, Bloomington and Fort Wayne.
The state, along with the Patient Preferences Coalition, a group that helped bring POST to Indiana, will begin educating medical professionals in a variety of facilities, spreading the program across the healthcare spectrum.