Final Act

Howard Rohleder

DESPITE WHAT’S SHOWN on TV medical shows, cardiopulmonary resuscitation (CPR) can be a traumatic procedure that has a low likelihood of success. Even if successful in immediately restarting the heart, the fact that it was necessary doesn’t bode well for long-term survival.

Some injuries or illnesses happen so suddenly that there’s little time to consider options. But for many, old age creeps up slowly or a serious illness drags on and worsens. This is the point where it’s helpful to have not just a living will and a health care power of attorney, but also a third document to assist those with illnesses such as terminal cancer, advanced heart or lung disease, or dementia. The “do not resuscitate,” or DNR, order tells health professionals not to undertake CPR if your heart stops.

Some states also recognize “physician orders for life sustaining treatment,” or POLST. Think of it as a super DNR. Where a DNR deals specifically with the resuscitation of a patient who has stopped breathing, a POLST gives orders about other advanced treatments, such as mechanical ventilation, antibiotics and feeding tubes, as shown in this video.

POLST orders can only be completed by a physician. Even if your state doesn’t legally recognize POLST, the national form can still be used as a basis for a conversation about your wishes with your physician and family.

The challenge for patients and families at the end-stage of cancer or any disease is deciding when further treatment runs counter to the patient’s desired quality of life. Making this decision requires an understanding of the possible treatments, their probability of success and the complications or side effects, as well as the likely costs.

Cost of care is a real concern, even if it’s uncomfortable to discuss. “Do everything” encompasses some very expensive interventions including a stay in an intensive care unit (ICU) at several thousand dollars per day, surgery, dialysis and transfers by ambulance or helicopter to tertiary hospitals. Depending on insurance, the costs may fall to the patient or the patient’s estate.

Consider a terminal cancer patient at home with no DNR or POLST who has sudden chest pain. The family calls 911. The paramedics arrive and have a legal obligation to do everything to treat the patient and take him or her to the nearest emergency department. “Everything” could include chest compressions that may break ribs, and placing a breathing tube, which—besides being uncomfortable—will reduce the ability to communicate.

Without a DNR or POLST, on arrival at the emergency department, the doctor and staff are legally obligated to do everything. “Everything” here means the continuation of what the paramedics began, and very likely connecting a ventilator and transferring care to the ICU. Despite these efforts, the outcome likely will be the same. On this, or during an inevitable next admission, the patient will die.

A living will does not change this. Only a DNR or POLST order can prevent or stop the treatment. This means handing the staff a copy of the order, not saying “she has one at home.”

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Hospice is a benefit provided by Medicare and insurance companies that can assist families in navigating end-of-life issues. Hospice staff can help sort out the patient’s wishes, reduce fear, and implement plans to keep patients comfortable and without pain, while working with families as they deal with the inevitable end.

In thinking about what the end might look like, doctors have a unique, first-hand perspective. Harvard Medical School studied the issue and found doctors themselves are less likely to have intensive medical care and less likely to die in the hospital. In his essay How Doctors Die, family physician Ken Murray relates how experienced clinicians view death and what they want for themselves. He found that doctors with terminal illnesses generally seek less treatment rather than more.

Dr. Atul Gawande’s book Being Mortal looks at how modern medicine and its miracles have lengthened lifespans and reduced early death. It’s gotten to the point, however, that actual old age and chronic illness have become, for many, a slow deterioration into a loss of autonomy and dignity.

Patients and families are looking for a chance at recovery. They may recall that there were health declines followed by rallies in the past. Recognition that a restoration of a meaningful life is no longer possible comes gradually, and it’s hard to accept. The question is whether death in an ICU—potentially with broken ribs and mechanical ventilation, while connected to tubes and technology—is the way to go. If that’s not what you want, planning can prevent it.

A conversation with your primary care doctor can help determine when a DNR or POLST order is appropriate. But know that the doctor may not be comfortable raising the topic until the patient asks the question first.

A DNR or POLST order can be revoked or replaced with an updated version. This requires a discussion with the doctor. Old copies should be retrieved and destroyed. They also can be suspended if a life event makes that desirable. For example, they may need to be suspended if surgery is needed.

The DNR, or POLST orders, if recognized, are governed by state law and must involve your physician. As with your living will and health care proxy, it’s necessary to communicate that they exist, starting with all family members. Copies should be readily available to hand to paramedics if an ambulance is called. All physicians caring for the patient should be aware of them, as well as any facility where the patient lives or is admitted for care.

Howard Rohleder, a former chief executive of a community hospital, retired early after more than 30 years in hospital administration. In retirement, he enjoys serving on several nonprofit boards, exploring walking paths with his wife Susan, and visiting their six grandchildren. A little-known fact: In May 1994, Howard was featured—along with five others—on the cover of Kiplinger’s Personal Finance for an article titled “Secrets of My Investment Success.” Check out his previous articles.

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8 months ago

Informative article. Sadly, my state does not recognize POLSTS. Very frustrating that one has no say over their own healthcare

8 months ago

This article is helpful but may present a somewhat simplistic discussion of end-of-life issues. I recently read the book “That Good Night” by the palliative care doctor Sunitra Puri and many of the stories are troubling. Patients can be near the end with cancer, emphysema, or other terminal illness and the medical staff are asking themselves why all the heroic measures (intubation, dialysis) are being done when it is futile. Yet in various cases the doctors have not told the patient they are dying, the spouse or a child insists “they are a fighter, they’ll come out of this like before, do everything”. In some especially sad cases a child has being taking care of an ill parent, there is a POA, the child has discussed the situation with the parent who just wants to be allowed to pass peacefully, then another child steps in to demand “do everything”. Everything means intubation with arms tied down, then breaking of ribs with CPR.

I don’t know the answer here, but I find this frightening.

Brent Wilson
Brent Wilson
8 months ago

This is an excellent article. I remember reading Being Mortal a few years back. I need to go back and re-read it, but I remember it being excellent and it made me think about “end-of-life” issues like I never had before. As mentioned in the book and this article, there are very costly interventions that loved ones often thrust upon the dying, even when there is little to no hope of recovery. But it’s not just financial cost, the dying can legitimately suffer due to these interventions, when they could be better served by being made as comfortable as possible during their final days.

8 months ago

I would only offer the caveat that theoretical “what if” discussions regarding end-of-life care can veer wildly off course when these decisions are encountered in real time. I’ve been present for some of these in the past, and have seen this from both the affected individual as well as family POAs. It’s difficult, if not impossible, to fully replicate the emotion that is involved in making these truly life altering decisions, but I agree with Howard that at the very least having these discussions is worthwhile, even if the implementation of advanced directives is fraught with turmoil.

8 months ago

Thank you for this. I have a DNR, which I carry with me, but I was horrified to discover recently that it would not be honored during an operation. I think that is completely wrong.

I have a list of detailed instructions, and my healthcare POA has a copy of them, but I was not aware of a POLST.

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