Myrtle’s Story

[Click Here to Access the 2009 California POLST Form in PDF]

Physician Orders for Life-Sustaining Treatment (POLST) legislation was passed in California and went into effect on January 1, 2009. Though healthcare providers are not required to use the POLST form, they are required to honor it. An adjunct to an advance directive, the POLST form is signed by the physician and the patient (or legally designated decision-maker) and outlines a plan of care that reflects the patient’s end-of-life wishes. The bright pink form (see next page) is designed for patients who are seriously ill and who are ready to make choices about limiting treatment, and it travels with patients across the continuum of care. The following narrative depicts how the use of the POLST form can facilitate patient preferences at the end of life.

When Myrtle Anderson’s husband died, she was troubled that he seemed to suffer so needlessly before his death, spending the last six weeks of his life in the intensive care unit on a ventilator. To ensure that she would not face a similar situation, she created an advance directive stating that she did not want extraordinary measures taken to keep her alive if she was terminally ill or permanently unconscious and put it in her safe deposit box.

One day, when Myrtle’s nephew Tom could not reach her by phone, he went to check up on her and found her lying on the floor, confused, and unable to speak. He called 911, and she was admitted to the hospital. At the hospital, the physician’s evaluation revealed a brain hemorrhage. When asked if she had drafted an advance directive, Tom reported that he didn’t know.

Once Myrtle was stabilized, the physician called her daughter, Carol, to discuss Myrtle’s current and future treatment. Carol and her mother had not spoken for several years. Carol stated that she had no idea what her mother would want and that she was unable to make any treatment decisions for her. As well, when Myrtle’s primary care physician was contacted, he reported that he and Myrtle had never discussed her wishes should she became ill and unable to speak for herself.

Myrtle’s condition improved slightly. Though she wasn’t able to speak clearly and had some difficulty swallowing, she was no longer confused. Tom helped arrange for her transfer to a skilled nursing facility (SNF) for speech rehabilitation. When she was asked at SNF admission if she had an advance directive, to everyone’s surprise, she nodded her head emphatically, “Yes!” Tom agreed to retrieve it.

When the physician caring for Myrtle at the SNF reviewed the advance directive with Myrtle, she indicated that her preferences for treatment were consistent with the statements in the document. Myrtle had not chosen an agent/decision-maker. The doctor asked if she could choose a surrogate, and Myrtle appointed Tom as her surrogate. The physician documented this in her record and suggested she complete a new advance directive that reflected this appointment.

The doctor also told Myrtle and Tom about the POLST form. The physician asked Myrtle about CPR, and she shook her head emphatically, “No!” The physician recognized and documented that Myrtle had decision-making capacity and checked “Do Not Attempt Resuscitation” on her POLST. Myrtle recognized that she had become quite debilitated and would, most likely, never be able to live independently. She chose “Limited Additional Interventions” in Section B and “No Artificial Nutrition by Tube” in Section C. She also said that she wanted Tom to make all her decisions for her, starting immediately, and told the physician not to bother her daughter. The POLST form went home with Myrtle when she was discharged.

Myrtle’s daughter, Carol, came to visit. The visit was pleasant, and Myrtle did not want to “stir things up” by telling Carol about the decisions she had made. While Carol was visiting, however, Myrtle collapsed, and Carol called 911. The emergency medical personnel found Myrtle’s bright pink POLST form on her refrigerator and transported it with her, along with her advance directive, to the hospital with her.

In the emergency room, EMS gave the staff the POLST form. They noted that Myrtle had chosen “Do Not Attempt Resuscitation” (DNR) and “Limited Additional Interventions.” Carol wanted everything done to save her mother and did not understand why the doctors were following the POLST form to guide her care.

Due to the severity of the stroke, Myrtle died. She was comfortable during the dying process. Tom was asked about tissue donation, and following Myrtle’s wishes, he consented to the donation of any tissue that might be useful.

Myrtle’s story is typical of many isolated elderly patients. Fortunately, there were adequate checks and balances in place at the hospital and at the SNF such that Myrtle’s wishes were solicited, documented, and ultimately followed. The use of POLST at a time when it was clear that Myrtle was ready to limit future treatment enabled her to die according to her values and beliefs.