October 2019 Oregon POLST Newsletter

In June of 2017, Oregon made the difficult and principled decision to separate from the POLST Paradigm Office as a result of the POLST Paradigm decision to liberalize their gift policy. While we share the goal of assuring patient wishes are honored, we disagree on the appropriate standards related to sources of funding. As health care shifts from fee-for-service to value-based care, there is a growing focus on reducing costs of care near the end of life. Reducing costs was not the intent of the POLST form. Rather, it is designed to accurately record a patient’s preference for emergency medical care for those nearing the end of life through shared decision-making between the patient and an unbiased health care professional. Any focus on financial incentives, including the practice of counting POLST form completion rates, opens the door to conflicting influences and can leave patients feeling pressured. To preserve voluntariness and the public trust, the Oregon POLST Program does not accept gifts from health care industry sources to avoid, either, a real or perceived appearance of conflict of interest.

In early October, the POLST Paradigm Office updated the national map. Previously identified as a ‘mature’ program, Oregon is now represented as ‘unaffiliated’. This new designation misrepresents the true maturity of the Oregon POLST program. This new designation suggests that Oregon is less mature than 43 other states in the nation, despite the fact that Oregon developed the POLST Program in the early 1990s and was the first state to earn a ‘mature’ status in 2013. Moreover, in response to the first attempt to diminish Oregon’s status in 2018, an independent investigation by the ONC determined that Oregon meets all ‘mature’ status requirements. Undervaluing Oregon’s experience and contributions adversely impacts POLST policy development. For example, the POLST Paradigm Office prohibited Oregon’s participation in the development of the proposed uniform POLST document. Oregon does not endorse the uniform document and has identified six critical elements of the proposed document that will, if implemented, adversely impact POLST use as other states mature. The Oregon POLST Program continues to lead by sharing its innovations and materials freely, while expecting appropriate attribution of Oregon’s ‘mature’ status — both to honor promises made during the separation, and to avoid unnecessary confusion for government agencies and others.

“The Oregon POLST Coalition reaffirms our endorsement of the authority of physician assistants to independently sign POLST orders without the counter signature of their supervising physician. In addition the Coalition endorses retaining the name (but not the signature) of their supervising physician on the back of the form. These standards have been approved by the Oregon Medical Board and have been in place since 2007. These standards are reflected in the current version of the Oregon POLST form. The Oregon POLST Coalition reaffirms our support of these standards.”

Approved by the Oregon POLST Coalition: October 17, 2019

Recent publications confirm the need to identify more consistently patients with POLST orders to limit treatment. The Board of Directors of the Oregon Chapter of the American College of Emergency Physicians (ACEP) approved the following statement regarding POLST on September 26, 2019:

"The Oregon Chapter of the American College of Emergency Physicians (Oregon ACEP) recommends that Emergency Departments implement a protocol to routinely check for Portable Orders for Life-Sustaining Treatment (POLST) forms for anyone 85 or older, and anyone coming to the ED from a residential care facility."

Before he became too sick to speak for himself, Dawn’s beloved husband, Jimmy, told her many times that he wanted to die at home if no further treatment was possible. “No machines,” he said. “Just let me go in peace.” When the time came, heartbroken as she was, Dawn agreed with the doctors that letting Jimmy die naturally, if his heart should stop, was what he would have wanted. But when she was asked to sign a POLST as his surrogate to officially designate his DNR status, Dawn felt overwhelmed by unbearable emotion. She felt unable to sign the form.

It is for this reason that the Oregon POLST form does not require a surrogate signature in situations like this. Studies show that the burden of emotional distress, and lasting symptoms of anxiety and guilt, some family members feel when they are asked to take active steps such as signing a form to withdraw or limit treatment for their loved ones. One family member reported that “I would not wish this on my worst enemy.” Oregon opposes the POLST Paradigm uniform document requirement that surrogates sign POLST forms, because doing so contributes to substantial suffering for family members like Dawn.