Regulating Hearts and Minds
The Mismatch of Law, Custom, and Resuscitation Decisions
Published in: Journal of the American Geriatrics Society, Vol. 51, No. 10, Oct. 2003, Editorial, p. 1502-1503
Posted on RAND.org on January 01, 2003
Washington State allows routine orders against resuscitation in hospitals or nursing homes but requires a special procedure and form for emergency medical workers not to perform resuscitation when the patient is anywhere else. If the Emergency Medical Service-No Cardiopulmonary Resuscitation (EMS-no CPR) form has not been signed by a physician and presented immediately upon the emergency workers arrival, emergency workers are obliged to initiate resuscitation. Yet most physicians did not know the process, and their patients could have had the protection against resuscitation that the law allows. In addition, the state Department of Health's website gives no information under such headings as "Do Not Resuscitate," "No CPR," or even the more general "Advance Directive." Today there are typically years between "get sick" and "die," with the average person having 2 to 3 years of disability before death. The federal Patient Self Determination Act (PSDA) went into effect in 1991, charging all healthcare providers who were paid by Medicare or Medicaid to ask patients whether they had an advance directive and to provide patients with information about their rights under state law concerning healthcare decision-making. This information could provide an opportunity to help patients to think about their options regarding the types and extent of medical care that they would want if they were no longer able to make those decisions themselves. The time is upon us to rethink how to evaluate resuscitation. People coming to the end of life with fragile health do not do well with resuscitation. Washington State is implementing a new policy to use a version of the Physician's Orders for Life Sustaining Treatment (POSLT) form. This more comprehensive form describes the patient's situation, names proxy decision makers and key contacts, and documents decisions concerning resuscitation and other medical interventions such as antibiotics and artificial feedings. The POLST procedure makes more sense than the old policy, because it addresses a range of considerations that affect patient well-being, and it stays with the patient in every setting. Being useful to the patient will make good advance care planning more appealing to physicians, but deliberate measures to encourage awareness and use of the POLST are also in order.