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Digital Lists Clarify End-of-Life Choices

http://online.wsj.com/article/SB10001424052748704610904576031740528446836.html

›DECEMBER 21, 2010
By SARA MURRAY

Oregon is making it easier for the seriously ill to voluntarily make their wishes known about end-of-life care by creating an electronic database that first responders can quickly check during a medical emergency.

At least two other states—West Virginia and New York—are developing similar systems, which are an outgrowth of signed paper forms. Known as physician orders for life-sustaining treatment, or Polst, the forms are supposed to direct all health-care providers about the type of care a patient wants to receive.

Paper-based systems are in use or in development in 33 states. Many people put the papers on their refrigerators or some other prominent location in their homes.

But paper forms are sometimes overlooked or lost. The electronic systems aim to make the information in these forms—such as whether a patient wants a feeding tube or even to be taken to a hospital at all—more readily available to an emergency worker, through a phone call or the Internet.

Whatever form they take, end-of-life care directives are controversial. Some critics argue that elderly or sick patients could be persuaded to choose less care in order to save money, even if that isn't their wish. Some opponents liken it to physician-assisted suicide.

"It will, in the long run, be a huge tool to hasten death," said Elizabeth D. Wickham, executive director for LifeTree Inc., a nonprofit antiabortion group opposed to the Polst program.

Another concern has been ensuring patient privacy while making information available to health professionals who need it. The systems also must be completely accurate.

"We can never contribute to someone getting less treatment" than they want, said Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health and Science University, where the electronic registry is housed.

Some 42,000 people have registered for Oregon's system since it was rolled out a year ago. Patients complete the form in consultation with their doctor, and the document is stored in a database accessible by staff at Oregon's emergency communication center, which coordinates statewide medical emergencies. Health-care providers can call the center, confirm the patient's identity by providing characteristics such as a birth date, and get instructions from the patient's Polst form.

The process generally takes less than two minutes. The center can then fax the form to the hospital. In the first year, about 350 calls were made to the communications center to check the forms.

Before the electronic registry, if emergency personnel couldn't find a form, they would provide any life-saving measures possible. "If that's against the patient's wishes, then are we really doing that patient a service?" asked Doug Kelly, division chief of emergency medical services for Redmond Fire and Rescue in Redmond, Ore., who also serves on an advisory committee that helps oversee the registry.

Being able to quickly check a form via phone "really does have large ramifications on how we determine to treat or not treat a patient in those stressful events," Mr. Kelly said.

Polst forms are different than living wills, because they are medical orders signed by a physician and are meant to be used by patients who are elderly or ill. In contrast, living wills can be completed by healthy individuals. They typically name a proxy who will make decisions about end-of-life care.

"We recommend that Polst be offered to people when their physician would not be surprised if they died in the next year," Dr. Tolle said.

A few other states are following Oregon's lead. West Virginia's system, set to debut in the middle of next year, would be accessible through the Internet, said Alvin Moss, director of the West Virginia Center for End-of-Life Care, which oversees that state's version of the Polst program. The goal is for health-care providers to eventually be able to access it on smart phones as well, said Dr. Moss.

In New York, a pilot program for a similar electronic registry is scheduled to begin early next year as well.

Polst forms usually offer three primary options: comfort care, limited intervention and full treatment. Comfort care includes administering medicine and oxygen, but no hospitalization. Limited intervention includes the previous measures, plus intravenous fluids and hospitalization. It excludes mechanical ventilation and intensive-care treatment.‹