Two articles recently published in The American Journal of Bioethics feature POLST:
(1) ‘ “Erring on the Side of Life” Is Sometimes an Error: Physicians Have the Primary Responsibility to Correct This,’ by Arthur Derse, JD, MD, and (2) ‘Controlling the Misuse of CPR Through POLST and Certified Patient Decision Aids,’ by Thaddeus Pope, JD, PhD.
Both were published January 23, 2017 in the online edition of the February issue of The American Journal of Bioethics as responses to the target article in the same issue, “Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish.” In this target article, authors Philip Rosoff and Lawrence Schneiderman voice concern over the “call to action” put out by The Institute of Medicine and the American Heart Association to expand the performance of cardiopulmonary resuscitation (CPR) in response to out-of-hospital cardiac arrest. Rosoff and Schneiderman instead make a plea for public education campaigns about the limitations of CPR and the reality of its outcomes which are often unfavorable especially under certain circumstances.
Derse points out in his article “Erring on the Side of Life” that cardiopulmonary resuscitation (CPR) is one of few medical interventions that individuals receive with little or no warning, let alone consent (in a medical culture which otherwise is heavily intent on informed consent). CPR is not inherently beneficial to all patients; but it somehow has become the standard treatment for all patients experiencing cardiac arrest, regardless of the likelihood for benefit.
Unfortunately, this is due in part to a popular misperception that CPR is vastly more successful than it actually is statistically. Secondly, physicians often do not wish to dissuade patients (or their surrogate decisions makers) from their decisions to opt for CPR, even when they would not opt for it themselves given the understanding of a dismal medical prognosis; this may be due to wishing to avoid conflict during a difficult time, and/or wanting to respect, however misguided, patient wishes.
Derse points out that physicians must bear the responsibility to educate patients about CPR outcomes so that they can decline this intervention, if the patient wants, based on a true understanding of likely outcomes, since it will be administered by default (unlike most medical treatments, which a patient would only receive after their express consent). Standing medical orders valid both within inpatient and out-of-hospital settings ought to document patient preferences, once thoughtfully determined with physician guidance, for any patient for whom cardiac arrest is a significant possibility.
The POLST Paradigm, Derse asserts, is “an effective means to assure that resuscitation orders are consistent with medical indications and patient preference,” with clearly identifiable prehospital orders regarding resuscitation and related orders. His final statement: Often there is an attitude of wanting to “err on the side of life”; but erring on the side of life is still an error to be avoided.
Pope highlights the importance of the POLST Paradigm, also. Like Derse, Pope points out the limitations of advance care planning for CPR as “worthwhile only if the patient’s preference are documented in a manner that assure implementation.” Unfortunately, clinicians administer CPR even to patients “who are permanently unconscious, severely demented, and in the last moments of their fatal disease”; it is “performed automatically unless the patient or surrogate has instructed otherwise… It is a unique medical procedure that clinicians must obtain consent not to perform.”
Thus, Pope asserts that “providing adequate incentives to clinicians and patient to engage in advance care planning is necessary but not sufficient” because its quality must also be ensured. Seriously ill patient must be helped to “understand the risks, benefits and alternatives to CPR” so that their documented instructions will “accurately reflect their preferences and values.” “Decision aids” such as educational videos may be helpful. But most importantly, the results of informed discussions “must be properly documented, so that they can be communicated to those who might administer CPR.”
“At least for the seriously ill,” Pope states, “there is already a validated tool for preventing unwanted out-of-hospital CPR: Physicians Orders for Life-Sustaining Treatment (POLST). Unlike advance directive, POLST Forms are immediately actionable and transportable. As medical orders, POLST Forms are followed by emergency medical service personnel in times of crisis. And they are followed by treating health care professionals once the patient has been transported to a health care facility. In short, seriously ill patients outside the hospital can materially reduce the chance of unwanted CPR by completing a POLST.”
- Rosoff, Philip and Lawrence Schneiderman (2017). Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish. The American Journal of Bioethics. 17 (2) 26-34 (limited access).
- Derse, Arthur R. (2017). “Erring on the Side of Life” Is Sometimes an Error: Physicians Have the Primary Responsibility to Correct This. The American Journal of Bioethics. 17 (2) 39-41 (limited access).
- Pope, Thaddeus. (2017). Controlling the Misuse of CPR Through POLST and Certified Patient Decision Aids. The American Journal of Bioethics. 17 (2) 35-37 (limited access).