According to the Dartmouth Atlas Report, health outcomes for New Jersey seniors are no better, and perhaps worse, when compared to other states. “Goals of care” are often not discussed, and elder patients spend their final weeks or months in a hospital setting.
During this time they may receive aggressive medical interventions they may likely have forgone had they been asked. Both the amount of time spent in the hospital and the intensity of physician services delivered in the hospital are higher in New Jersey than in any other state. Many would think New Jersey’s aggressive use of hospital services would bring better health outcomes and greater satisfaction with healthcare but it has not.
Seniors in New Jersey can expect to see more doctors and undergo more tests during their final years of life than in any other state. While this high level of service may sound beneficial, its had a negative impact on the quality of life for many older citizens.
Ageism at the bedside is also an important barrier to good decision making. This prejudice occurs across the spectrum of medical providers and negatively impacts quality and satisfaction. Very old patients are sometimes denied surgery or entry into an intensive care unit simply because of that person’s age. Without a discussion of goals of care, physicians will continue to either deliver unwanted or withhold wanted services to the older patient.
Bringing Autonomy Back to End-of-Life Treatment Decisions
How can an elderly patient be proactive in their end-of-life treatment? At times, it may seem difficult to have those opinions heard in the fast-paced and impersonal routine of our current health care system. With physicians administering conventional treatments and family members disagreeing with end-of-life attitudes, elderly patients can become overwhelmed and discouraged in giving their position o how they want to be treated in their final years of life.
New Jersey Goals of Care is fighting to empower senior patients and make their goals central to all decision-making that occurs at the bedside. We are working on several fronts to alight individual goals of care with medical treatments, thereby eliminating burdensome care and ageism. One new tool is the POLST (Physician Orders for Life Sustaining Treatments) form. Centered around University Medical Center at Princeton, New Jersey Goals of Care is conducting the largest POLST pilot in the state, gathering important data on the use of the form and on its future for New Jersey’s seniors.
What is the POLST Form?
The form is a one-page physician order form that addresses patient goals, scope of therapies, artificial nutrition and resuscitation status for those entering their final years of life. It is completed and signed only by a physician or nurse practitioner and is meant to complement – not replace – the written advance directive. In states that have POLST programs, the form is portable across healthcare settings, from hospital to post-acute levels of care and even to the private home. In December of 2011, Governor Christie signed the POLST bill into law. The final NJ POLST form is expected to be available within the next year. There is no better time than the present for seniors and their families to become more familiar with the POSLT form.
Who is Eligible for the POLST Form?
According to the bill signed by Governor Christie, The POLST form is recommended for those patients entering the final five years of life. It is during this time that they patients are exposed to an increase of medical services. Although not required, it is recommended that practitioners discuss and document the patient’s “Goals of Care” and that the DNAR (Do Not Attempt Resuscitation) order be discussed in the context of the patient’s prognosis.
Of course the patient is always the primary decision-maker. If the patient does not have capacity, the medical team should ask for written advance directive, and if appropriate, take instruction from this document. If no directive exists or if it does not address the issues at hand, decisions should be made based on the principle of substituted judgment per next of kin (e.g., “What would the patient instruct us to do if he/she could speak now?”).
Completing a POLST form is vital for elderly patient to ensure that the treatment they receive will allow them to achieve the plans they have for their final years of life. Whether it’s living independently, dying a peaceful death at home or attending at grandson’s wedding next spring, having a POLST form will ensure that a patient’s therapies will be organized around their personal goals.
~ David Barile, MD and Carla Pardee