Ask Doctor K: Going beyond the durable do not resuscitate order

DEAR DOCTOR K: My husband has terminal cancer. He has already signed a do-not-resuscitate order. His doctor recently suggested that he also complete a new form called a “POLST.” Can you explain what this is?

DEAR READER: As you know (but other readers might not), a Durable Do Not Resuscitate Order (DDNR) lets your husband’s medical team know that he does not want CPR if his heart stops beating or he stops breathing. It’s usually for people who are near the end of their lives or have an illness that won’t improve. It takes the burden of decision-making off family members.

A POLST is a relatively new initiative that takes DDNRs even further. Like the DDNR, the POLST (Physician’s Orders for Life-Sustaining Treatment) form turns your husband’s health care preferences into a medical order that must be followed by doctors, hospital staffers and paramedics.

The POLST provides instructions for treatments beyond CPR. For example, it covers such issues as when he wants the doctors to prescribe pain medicine, antibiotics and nutrition. It’s for use both inside and outside of the hospital setting.

The POLST is not a legal document. It’s a medical order signed by your husband, your physician and a witness. For it to be most effective, it must be in the possession of someone close to your husband when he is seriously ill, and major medical decisions need to be made. Most likely, that someone will be you or his doctor.

Many states are just developing their POLST forms. They may call them by another name, such as a MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), or a MOST (Medical Orders for Scope of Treatment).

One important issue to consider is this: POLSTs can dictate very specific treatment that’s based on a person’s needs when he or she signs the form. But there’s no process in place to revisit the POLST if and when a person’s physical status changes. Suppose your husband no longer agreed with the instructions in his POLST, but was not able to communicate with physicians. In that situation, the POLST could be a problem.

It may help to have other documents in place that spell out your husband’s wishes. Not just medical orders, but legal documents that also fall under the umbrella term of an advance directive. These include:

– A LIVING WILL. This legal document formalizes your treatment preferences if you’re unable to make your own health care decisions. It is drafted by an attorney. A living will can spell out the same detailed instructions as a POLST.

– A HEALTH CARE PROXY OR SURROGATE. This is a legal document that names a person who is empowered to make decisions for your husband if he lacks the capacity to make them. Speaking openly with your husband about the care he wants may be the most important thing you can do to be sure he receives the treatment he wishes.

Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.