POLST: When Advance Directives Are Not Enough
When Max was confronted with difficult decisions about the care he wanted in the face of his advancing illness, he took comfort in the fact that his wish for a peaceful, natural death was clearly documented in an Advance Directive. Tragically, Max and his loving family discovered that the Advance Directive did not ensure that these wishes would be honored at a time of medical crisis. POLST would have made a difference.
Born and raised in rural Oregon, Max lived his days with rare passion and spirit.
“He was funny, delightful and charming,” recalls his widow, Suzanne. “A real rascal,” she adds, with a twinkle in her eye, and she gladly accepted her role as the perfect foil to his endless repertoire of jokes and roguish humor.
A devoted father and doting grandfather, Max was a gifted athlete—a champion squash player, who loved to play golf, hunt and fish. He was also notoriously late for everything. But his infectious charm invited instant forgiveness and he was invariably the heart and soul of any gathering.
Max’s active lifestyle was dealt a life-changing blow around the time of his 75th birthday when he received the sobering diagnosis of aortic stenosis. Open heart surgery was his only treatment option, and the alternative was an increasingly frail state of health as the valve slowly closed. He thought deeply about his choices, especially given his other health problems. And the conclusion he reached was crystal clear: he did not want the surgery.
Although he loved technology, and had embraced it in his work, he was, according to Suzanne, “a man of nature.” He was adamant that he wanted his life, and death, to unfold naturally—without tubes or machines. So, with great care, he completed an Advance Directive to document his end-of-life wishes, which he then shared with his family.
“He was very clear about what he wanted,” says Suzanne. “And we were all comfortable with his decision, knowing that he believed in the quality of life and had thought about it carefully based on who he was and how he wanted to live out his days.”
Sadly, this careful planning was not enough. Five years later, when Max collapsed from heart failure while playing golf on Mother’s Day, his strongly-held wishes could not be honored. His Advance Directive, completed with such care and intention, did not serve as the medical orders needed to direct his care in this emergency situation.
Max had just hit a good drive off the first fairway when his heart gave out. An ambulance was called to the scene and, when Suzanne arrived about 15 minutes later, she was deeply disturbed by what awaited her.
Emergency medical personnel were clustered around her lifeless husband, doggedly performing CPR in an attempt to revive him. And she realized with horror that this was exactly what Max had most wanted to avoid.
She repeatedly begged the EMTs to stop. “I said that my husband did not want this and that I had his Advance Directive in my purse,” remembers Suzanne of this traumatic day.
“I touched him and I knew he was dead. But they kept going. And I looked around at all the people watching, and I thought to myself that Max—who was a very private man—would not have wanted this at all. He would have hated it.”
Today, reliving these painful memories, Suzanne is deeply committed to honoring the memory of her husband by raising awareness about the importance of a POLST (Physician Orders for Life-Sustaining Treatment) form to document the treatment wishes of people living with advanced illness.
In a medical emergency, EMTs have no choice but to do everything possible to save a life unless they have medical orders to the contrary. Only a POLST form provides the medical orders necessary to turn patients’ wishes about the treatment they do and do not want into action.
“For people who are as sick as Max and who have strong feelings about the treatments they want and don’t want, Advance Directives are not enough,” cautions Susan Tolle, MD, director of the Center for Ethics in Health Care at Oregon Health & Science University.
Max’s death would have been very different if the EMTs responding to his collapse had had a POLST form to direct the course of his care. He would have been allowed the dignified natural death he deeply desired. And his family, in their grief, would have had the comfort of knowing that his wishes had been both honored and respected.