It’s the conversation many avoid for too long: What kind of medical treatment do you want if you are frail or seriously ill? Do you want whatever treatment is necessary, even if it means a trip to the hospital or being on a breathing machine? Do you want comfort measures only, inside the walls of your own home?
When you are seriously ill or frail, your loved ones and health care providers should know exactly what kind of medical treatment you want, or, more importantly, don’t want. So who should be leading this delicate conversation? Insurance companies have implemented ways to talk to patients about their options, but these conversations should be happening in a health care setting.
Primary care professionals are in the best position to explore changes in their patients’ health care goals over time. I shared this viewpoint with the New England Journal of Medicine last year as part of a larger discussion around end-of-life care. They, rather than insurance companies, must step up, lead and coordinate these conversations.
OHSU School of Medicine in Portland, Oregon, offers an innovative course where “patient-teachers” like 76-year-old Bob Samuels work with medical students to teach them how to have these often difficult and sensitive conversations in a respectful and professional manner.
Less than 10 percent of Americans report they want to die in the hospital, and yet without predefined medical orders, many do. Primary care professionals in 21 states now are able to talk about a patient’s options, thanks to the Physician Orders for Life-Saving Treatment (POLST) paradigm. (Another 23 states are in the process of developing a program.) The POLST form is a medical order that gives people with a serious illness or frailty control over the treatments they do or do not want to receive in an emergency situation.
Research has shown POLST works. Having predefined medical orders is strongly associated with getting the level of treatment you want and reducing unwanted hospitalization at the end of life. The POLST form turns patients' wishes into action, with medical orders complementing the advance directive when patients are ready to say what they want to happen should a medical crisis happen today.
We need to design new structures and tracking systems within primary care to provide supportive outreach to patients with advanced illnesses. We also need to own that this is our responsibility and then work out the logistics of how to effectively and consistently provide this outreach.
Go to OregonPOLST.org to find out more about Oregon’s POLST program.
Susan Tolle, M.D., is director of the Center for Ethics in Health Care at OHSU, and professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine.