Policy Practicum: Endstage Decisions: Health Directives in Law and Practice
Medical decisions toward the end of life can be crucial and difficult for patients, doctors, and the families of patients. Law and medicine have been struggling to find ways to strike a balance between what the patients might want (or say they want), and what makes medical, economic, and ethical sense. People have been encouraged to fill out “Advanced Health Care Directives,” which give guidance to doctors and surrogates (usually a family member) on what to do when faced with end-of-life dilemmas. Another form, adopted in just over half the states (including California) is the POLST form (Physician Orders for Life-Sustaining Treatment). The two types are supposed to complement each other, but they are different in important ways. The Advanced Health Care Directive expresses what a person wants, or thinks she wants, and/or appoints a surrogate, in case the patient is unable to express her wishes. Anybody can fill out a Directive, at any time of life. Ideally, a copy goes to the surrogate, if one is appointed, and another to the primary care physician. The POLST form is meant for people who are seriously ill. It is a one page form, printed on bright pink paper. It is signed by patient and doctor. The directives (for example “no artificial nutrition by tube”) are supposed to be controlling; the patient, of course, can change her mind; but there is no surrogate. It is an agreement between the patient and the doctor. Who uses these forms? How effective are they? To what extent and in what situations are they useful? In what situations are they not useful? Can they be made more useful and, if so, how?