Legal briefing: POLST: Physician orders for life-sustaining treatment

Journal of Clinical Ethics

Volumn 23, Issue 4, 2012, Pages 353-376

  Pope, Thaddeus Mason ^a,b   Hexum, Melinda ^b  

^a Health Law Institute   (United States)

^b HAMLINE UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CLINICAL PRACTICE; ELECTRONIC MEDICAL RECORD; ETHICS; GOVERNMENT; HUMAN; JURISPRUDENCE; LEGAL ASPECT; LIVING WILL; LONG TERM CARE; PATIENT CARE; PROGRAM DEVELOPMENT; RESUSCITATION; UNITED STATES;

ADVANCE CARE PLANNING; ADVANCE DIRECTIVES; ELECTRONIC HEALTH RECORDS; FEDERAL GOVERNMENT; HUMANS; JURISPRUDENCE; LIFE SUPPORT CARE; PHYSICIAN'S PRACTICE PATTERNS; PROGRAM DEVELOPMENT; RESUSCITATION ORDERS; UNITED STATES;

MLCS; MLOWN;

EID: 84875800658     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (315)

1. This article focuses on legal issues intrinsic to POLST. Other commentators have already examined extrinsic legal obstacles to adopting POLST. S. E. Hickman, C. P. Sabatino, A. H. Moss, J. W. Nester, "The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation", Journal of Law, Medicine, and Ethics 36, no. 1(2008):119-40. Nor does this article discuss related issues pertaining to advance directives, surrogate decision making, or out-of-hospital DNAR orders.
2. R. Miller, "Physician Orders to Supplement Advance Directives: Rescuing Patient Autonomy", The Journal of Clinical Ethics 20, no. 3(Fall 2009):212-9;
3. T. Pope, "Legal Briefing: Advance Care Planning", The Journal of Clinical Ethics 20, no. 4(Winter 2009):289-96.
4. C. P. Sabatino, Improving Advanced Illness Care: The Evolution of State POLST Programs (Washington, D. C.: AARP, 2011).
5. "Care at the End of Life", editorial, New York Times, 25 November 2012, at SR10.
6. Minnesota Medical Association, "POLST Communications", http://www.mnmed.org/Key Issues/POLSTCommunications/tabid/3291/Default. aspx, accessed 10 December 2012;
7. Montana Board of Medical Examiners, "POLST", http://bsd.dli.mt. gov/license/bsd-boards/med-board/polst.asp, accessed 10 December 2012.
8. Aging Institute of UPMC Senior Services, "Professionals in Aging: Pennsylvania Orders for Life-Sustaining Treatment (POLST)", http://www.agmg. pitt.edu/professionals/resources-polst.htm, accessed 10 December 2012.
9. 18 Vt. Stat. Ann. § 9708.
10. "Program Description for: Connecticut", http://www.ohsu.edu/ polst/programs/connecticut. htm, accessed 10 December 2012;
11. Del. Admin. Code 4304-1.0-14.0;
12. Md. Code. Ann., Health-Gen. § 5-608. 1;
13. Mass. Acts, ch. 305, sec. 43;
14. N. Y. Department of Health, Bureau of Emergency Medical Services, "Policy Statement 11-02 (1 March 2011);
15. "Program Description for: Ohio", http://www.ohsu. edu/polst/programs/documents/OHProgramDescription.pdf (27 October 2008);
16. Ind. H. B. 1114 (2012);
17. M. A. O'Rourke et al., "Physician Order for Scope of Treatment (POST) in South Carolina (SC)", Journal of Clinical Oncology 30(2012):Suppl. 34, abstract 21;
18. Tenn. Comp. R. and Regs. 1200-08-01-.13;
19. "Program Description for: Virginia", http://www.ohsu.edu/polst/ programs/documents/developing stateform-Virginia-5-29-12.pdf, accessed 10 December 2012;
20. W. Va. Code § 16-30-25.
21. La. Rev. Stat. Ann. § 40:1299.64.2 (5).
22. "Program Description for: Alaska", http://www.ohsu.edu/polst/ programs/documents/AKProgramDescription.pdf (5 December 2008);
23. Colo. Rev. Stat. Ann. § 15-18.7-104;
24. Ky. S. B. 217, 2012 Leg., Reg. Sess. (2012);
25. Program Description for: New Mexico", http://www.ohsu.edu/polst/ programs/documents/NMdevelopingstateform.pdf (23 January 2012);
26. N. C. Gen. Stat. Ann. § 90-21. 17.
27. Iowa Code § 144D. 1-.4.
28. Nevada Center for Ethics and Health Policy, "An Introduction to the Nevada SMOST", http://www.unr.edu/ncehp/spost-summary.html, accessed 10 December 2012.
29. Still other similar acronyms have some currency. K. B. Newport et al., "The 'PSOST': Providers' Signout for Scope of Treatment", Journal of Palliative Medicine 13, no. 9(2010):1055-8. But PSOST has a narrower mission than POLST. It is an internal tool for smooth transitions on nights and weekends.
30. "Transportable Physician Orders for Patient Preferences (TPOPP)", http://www.practical bioethics.org/initiatives/transportable- physicianorders.html, accessed 10 December 2012.
31. Utah Bureau of Emergency Medical Services, "Life with Dignity/POLST/DNR", http://www.health.utah.gov/ems/polst, accessed 10 December 2012.
32. 20 Ill. Comp. Stat. § 2310-600 (b-5).
33. Department of Veterans Affairs, Veterans Health Administration, VHA Handbook, § 1004.04 (25 October 2012).
34. C. P. Sabatino, "The Evolution of Health Care Advance Planning Law and Policy", Milbank Quarterly 88, no. 2(2010):211-39;
35. L. S. Castillo et al., "Lost in Translation: The Unintended Consequences of Advance Directives Law on Clinical Care", Annals of Internal Medicine 154, no. 2(2011):121-8;
36. K. E. Sonderling, "POLST: A Cure for the Common Advance Directive-It's Just What the Doctor Ordered", Nova Law Review 33, no. 2(2009):451-80;
37. M. B. Kapp, "The Nursing Home as Part of the POLST Paradigm", Hamline Law Review 36, no. 2 (2013);
38. H. S. Perkins, "Controlling Death: The False Promise of Advance Directives", Annals of Internal Medicine 147, no. 1(2007):51-7; (Pubitemid 351688342)
39. A. Fagerlin and C. E. Schneider, "Enough: The Failure of the Living Will", Hastings Center Report 34, no. 2(2004):30-42.
40. P. A. Bomba, M. Kemp, and J. S. Black, "POLST: An Improvement over Traditional Advance Directives", Cleveland Clinic Journal of Medicine 79, no. 7(2012):457-464;
41. C. Spillers and B. Lamb, "Is the POLST Model Desirable for Florida?" Florida Public Health Review 8(2011):80-90.
42. For detailed explanations of POLST (customized for clinician, lawyer, and patient audiences in multiple languages), see the extensive training resources on the California, New York, Oregon, and West Virginia program websites. Coalition for Compassionate Care of California, "POLST-Physician Orders for Life-Sustaining Treatment: For Health Care Providers", http://www.capolst.org/?for=providers, accessed 10 December 2012;
43. Compassion and Support at the End of Life, "Medical Orders for Life-Sustaining Treatment-Professionals", http://www.compassionandsupport. org/index.php/for-professionals/molst-trainingjcenter, accessed 10 December 2012;
44. Center for Health Care Ethics, Oregon Health and Science University, "Oregon POLST Information for Health Care Professionals, POLST", http://www.ohsu.edu/polst/programs/OregonHealthCareProfessionals.htm, accessed 10 December 2012;
45. West Virginia Center for End-of-Life Care, "Information about Completing Effective Advance Directives and POST Forms", http://www.wvendoflife.org/POST, accessed 10 December 2012.
46. P. A. Bomba, "Landmark Legislation in New York Affirms Benefits of a Two-Step Approach to Advance Care Planning Including MOLST", Widener Law Review 17, no. 2(2011):475-500.
47. B. J. Hammes et al., "The POLST Program: A Retrospective Review of the Demographics of Use and Outcomes in One Community Where Advance Directives Are Prevalent", Journal of Palliative Medicine 15, no. 1(2012):77-85;
48. S. E. Hickman et al., "The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form", Journal of the American Geriatrics Society 59, no. 11(2011):2091-9;
49. S. E. Hickman et al., "A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life-Sustaining Treatment Program", Journal of the American Geriatrics Society 58, no. 7(2010):1241-8;
50. S. E. Hickman et al., "Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting", Journal of Palliative Medicine 12, no. 2(2009):133-41;
51. M. A. Lee et al., "Physician Orders for Life-Sustaining Treatment (POLST): Outcomes in a PACE Program", Journal of the American Geriatrics Society 48, no. 10(2000):1219-25;
52. S. W. Tolle, V. P. Tilden, C. A. Nelson and P. M. Dunn, "A Prospective Study of the Efficacy of the Physician Order Form for Life-Sustaining Treatment", Journal of the American Geriatrics Society 46, no. 9(1998):1097-102. (Pubitemid 28415598)
53. See Center for Ethics in Health Care, Oregon Health and Science University, "POLST State Programs", http://www.ohsu.edu/polst/ programs/state+programs.htm (September 2012). Maryland also has a legislatively established MOLST program that is not registered with the National POLST Paradigm program. Md. Code. Ann., Health-Gen. § 5-608.1 (Wesf 2012);
54. "Maryland MOLST", http://marylandmolst.org/, accessed 10 December 2012. Four other states (Alabama, Arkansas, Oklahoma, and South Dakota) also have no POLST program affiliated with NPPTF. But, like Maryland, some of these states have been developing a POLST program.
55. Center for Ethics in Health Care, Oregon Health and Science University, "History of the POLST Paradigm Initiative", http://www.ohsu.edu/polst/ developing/history.htm, accessed 10 December 2012.
56. "Program Description for: Wisconsin", http://www.ohsu.edu/ polst/programs/documents/WIProgramDescription.pdf (28 July 2005).
57. "Program Description for: New York", http://www.ohsu.edu/polst/ programs/documents/NYProgramDescription082908FINAL.pdf (29 Aug. 2008).
58. "Program Description for: Pennsylvania", http://www.ohsu.edu/ polst/programs/documents/ProgramDescriptionPA-END.pdf (1 November 2010).
59. Center for Health Care Ethics, "Program Requirements", http://www.ohsu.edu/polst/developing/core-requirements.htm (26 April 2012).
60. S. E. Hickman et al., "Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting", Journal of Palliative Medicine 12, no. 2(2009):133-41, 135, reporting that 100 percent of hospices in Oregon and 85 percent of hospices in West Virginia used POLST. The vast majority of these hospices (92 percent in Orgeon and 73 percent in West Virginia) had POLST forms for more than half of their patients.
61. N. S. Wenger et al., "Implementation of Physician Orders for Life Sustaining Treatment in Nursing Homes in California: Evaluation of a Novel Statewide Dissemination Mechanism", Journal of General Internal Medicine (10 August 2012); DOI: 10.1007/sl 1606-012-2178-2.
62. D. M. Zive and T. A. Schmidt, Pathways to POLST Registry Development: Lessons Learned (2012) (describing the efforts of California, New York, Oregon, and West Virginia to develop and fund electronic POLST registries in effort to reduce barriers to use of POLST in emergency situations and generate data for research and monitor/evaluation).
63. "Program Description for: Tennessee", http://www.ohsu.edu/ polst/programs/documents/TNProgramDescription.pdf (6 February 2009).
64. "Program Description for: Hawaii", http://www.ohsu.edu/polst/ programs/documents/HIProgram Description.pdf (26 October 2009).
65. "Program Requirements", http://www.ohsu.edu/polst/developing/ core-requirements.htm, accessed 10 December 2012.
66. "Program Description for: Massachusetts", http://www.ohsu.edu/ polst/programs/documents/MAProgramDescription.pdf (10 May 2010).
67. 2008 Mass. Acts, ch. 305, sec. 43 (directing the establishment of a POLST pilot program, which would facilitate recommendations for establishment of a statewide MOLST program). The Massachusetts MOLST website also provides links to the reports and recommendations based on the demonstration program experience. "About MOLST in Massachusetts", http://www.molst-ma.org/about, accessed 10 December 2012.
68. Massachusetts Dept, of Publ. Health, Office of Emergency Medical Services, "Emergency Medical Services Pre-Hospital Treatment Protocol", http://www.mass.gov/eohhs/provider/guidelines-resources/ clinical-treatment/public-health-oems-treatment-protocols.html (10th ed., 1 March 2012).
69. Massachusetts Dept, of Publ. Health, "Circular Letter DHCQ 12-3-560", http://www.molstma.org/sites/molst-ma.org/files/DHCQ-560.pdf (20 March 2012).
70. "MOLST Expansion Throughout Massachusetts Has Begun", http://www.molst-ma.org/healthcare-professionals, accessed 10 December 2012.
71. Iowa Dept, of Publ. Health, "Iowa Physician Orders for Scope of Treatment Form", https://idph.state.ia.us/IPOST/Form. aspx (25 June 2012).
72. The IPOST website also provides a links to guidelines for completion and use of IPOST. https://idph.state.ia.us/IPOST/Form.aspx, accessed 10 December 2012.
73. "Program Description for: New Mexico", http://www.ohsu.edu/ polst/programs/documents/NMdevelopingstateform.pdf (23 January 2012).
74. "Program Description for: Ohio", http://www.ohsu.edu/polst/ programs/documents/OH ProgramDescription.pdf (27 October 2008);
75. D. Cluxton and M. Sweterlisch, "Getting Acquainted with MOLST", (22 February 2011), http://206.21.86. 1 l/SiteObjects/B6766D956ACCFA 782 Fl3938BE01AD760/MOLSTHandouts.pdf, accessed 10 December 2012. POLST advocate, the Midwest Care Alliance, "continues to work on draft legislation to replace DNR law in Ohio with Medical Orders for Life Sustaining Treatment (MOLST).
76. We are working with the many stakeholders involved to reach consensus on legislative language before the bill can be introduced. To that end, a stakeholder meeting has been scheduled for September 25, 2012." Midwest Care Alliance, "Pulse", http://www.ohpco.org/aws/MCA/pt/sd/news- article/62980/-PARENT/Iayout-details/false (4 September 2012). Bills introduced in earlier sessions had been defeated. Ohio H. B. 601 (2008) (noting that existing state laws can impose a number of barriers to implementation of POLST, including limits on the authority of surrogate decision makers, lack of default surrogate laws, medical preconditions or witnessing requirements for withholding of life-sustaining treatment, and detailed out-of-hospital DNR laws). While most of these barriers, particularly medical preconditions or lack of default surrogate provisions, are not an absolute bar, they can limit the utility of POLST or make implementation of POLST more difficult.
77. Ga. H. B. 247(2011), enacted as 2012 Ga. Act 580, codified at Ga. Code Ann. § 29-4-18 (k) (3).
78. K. L. Cerminara and S. M. Bogin, "A Paper about a Piece of Paper: Regulatory Action as the Most Effective Way to Promote Use of Physician Orders for Life-Sustaining Treatment", Journal of Legal Medicine 29, no. 4(2008):479-503, 500.
79. La. Atty. Gen. Op. 08-0289 (26 November 2007). Notably, due to concern over whether new MOLST regulations were consistent with governing EMS statutes, the Department of Health and Social Services instructed all healthcare providers to "refrain from further use" of MOLST. Letter from K. T. Rattay, Director, Division of Public Health, Delaware Department of Health and Social Services (14 November 2012), http://www.meds0cdel.0rg/P0rtals/l/In%20the%20News/ MOLST%20Form %20Letter %20111412.pdf, accessed 10 December 2012.
80. VHA Handbook 1004. 04 §§ 3 (f) and 7 (a).
81. Cal. Prob. Code §§ 4780-86 (West 2012) (adopted 2009);
82. Colo. Rev. Stat. Ann. § 15-18. 7 (West 2012) (adopted 2010);
83. Ga. Code Ann. § 29-4-18 (k) (3) (West 2012) (adopted 2012);
84. Haw. Rev. Stat. §§ 327K-1 to K-4 (West 2012) (adopted 2009);
85. Idaho Code Ann. §§ 39-4512 to -4514 (West 2012) (adopted 2006);
86. Ill Comp. Stat. Ann. § 2310/2310-600 (b-5) (West 2012) (adopted 2011);
87. Iowa Code Ann. § 144D.1-.4 (West 2012) (adopted 2012);
88. La. Rev. Stat. Ann. § 1299. 64.1-.6 (2012) (adopted 2010);
89. Md. Code Ann., Health-Gen. § 5-608. 1 (West 2012) (adopted 2011);
90. N. C. Gen. Stat. Ann. § 90-21. 17 (West 2012) (adopted 2007);
91. N. J. Stat. Ann. § 26:2H-130 to -140 (West 2012) (adopted 2011);
92. N. Y. Pub. Health Law § 2994-dd (6) (McKinney 2012) (adopted 2010, although 2008 legislation permitted statewide use of MOLST across healthcare settings);
93. Pa. Cons. Stat. Ann. § 5488 (adopted 2006);
94. R. I. Gen. Laws Ann. § 23-4. 11-3.1 (West 2012) (adopted 2012);
95. Tenn. Code Ann. § 68-11-224 (West 2012) (adopted 2004;
96. Utah Code Ann. § 75-2a-106 (West 2012) (adopted 2008);
97. Vt. Stat. Ann. tit. 18, §§ 9701, 9707, 9709 (West 2012) (adopted 2005, amended 2011);
98. W. Va. Code § 16-30-25 (West 2012) (adopted 2002).
99. See La. Rev. Stat. Ann. § 40:1299.64.2 (8).
100. Ga. Code Ann. § 29-4-18 (1);
101. Ill. Comp. Stat. Ann. § 2310/2310-600 (b-5);
102. N. Y. Pub. Health Law § 2994-dd (6);
103. Pa. Cons. Stat. Ann. § 5488;
104. Tenn. Code Ann. § 68-11-224;
105. N. J. S. 2197, enacted as 2011 Pub. Laws Ch.
106. 145, codified as N. J. Stat. Ann. § 26:2H-130 to -140. A Wyoming bill similarly would have delegated the details. Wyo. H. B. 75 (2012).
107. "Simplicity and economy of language are also highly recommended to retain sufficient clinical flexibility to make continuing improvements to the program." Center for Ethics in Health Care, Oregon Health and Science University, "Considering Legislation: When Selected Regulation Change is Not Enough", http://www.ohsu.edu/polst/resources/legalissues.htm, accessed 10 December 2012.
108. Cal. Prob. Code § 4780 (a) (2) (B) (3).
109. Cal. Prob. Code § 4780 (c) (directing that "the health care provider, during the process of completing the Physician Orders for Life-Sustaining Treatment form, should inform the patient about the difference between an advance health care directive and the Physician Orders for Life-Sustaining Treatment form").
110. See, e.g., Cal. Prob. Code § 4780 (c) (requiring that the form be completed based on patient preferences and signed both by the physician and the patient or the patient's legally-recognized decisionmaker);
111. Cal. Prob. Code § 4783 (a) (requiring the following language be included on the form: "by signing this form, the legally recognized health care decision maker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form").
112. See, e.g., Cal. Prob. Code § 4780 (b) (authorizing a legally recognized healthcare decision maker to execute a POLST on behalf of a patient if the patient lacks capacity or has authorized the decision maker to do so on his/her behalf);
113. Cal. Prob. Code § 4781. 2 (requiring a legally recognized health care decision maker to consult with the patient's physician before attempting to modify the patient's POLST).
114. Cal. Prob. Code § 4782.
115. Cal. Prob. Code § 4785.
116. W. Va. Code § 16-30-25 (b) (1) - (5).
117. Ga. H. B. 247(2011), enacted as 2012 Ga. Act 580,
118. codified at Ga. Code Ann. § 29-4-18 (k) (3);
119. Ill. H. 3134(2011), codified at 20 111.
120. Comp. Stat. Ann. § 2310/2310-600 (b-5);
121. Iowa H. F. 2165(2012),
122. codified at Iowa Code Ann. § 144D.1-.4;
123. Md. H. B. 82, enacted as Md. 2011 Acts Ch. 434,
124. codified at Md. Code Ann., Health-Gen. § 5-608. 1;
125. N. J. S. 2197, enacted as 2011 Pub. Laws Ch. 145,
126. codified at N. J. Stat. Ann. § 26:2H-130 to -140;
127. R. I. H. B. 7735 and S. B. 2361(2012), enacted as Pub. Laws 187 and 199,
128. codified at R. I. Gen. Laws Ann. § 23-4.11-3.1;
129. Vt. H. 201, enacted as 2012 Acts 60,
130. codified at 18 Vt. Stat. Ann. § 9708.
131. In 2010, Georgia had enacted a statute instructing the "Department of Public Health [to] develop and make available a Physician Order for Lifesustaining Treatment, a specific form voluntarily executed by a patient and his or her authorized representative and a physician which provides directions regarding end of life care." 2010 Ga. Laws, Act 616,
132. codified at Ga. Code Ann. § 29-4-18 (1).
133. 20 Ill. Comp. Stat. Ann. § 2310/2310-600 (b-5) (West 2012). The Illinois Department of Health is expected to approve a proposed form in early 2013.
134. Iowa Code Ann. § 144D.1-. 4;
135. Md. Code Ann., Health-Gen. § 5-608. 1;
136. N. J. Stat. Ann. § 26:2H-130 to -140;
137. R. I. Gen. Laws Ann. § 23-4.11-3.1.
138. Vt. Stat. Ann, tit. 18, § 9708 (b). Vermont healthcare facilities and residential care facilities "may document DNR/COLST orders in the patient's medical record in a facility-specific manner when the patient is in their care", but are required to use the Department of Health-issued form for patients who are not admitted to healthcare/residential care facilities or who are transferred from such facilities.
139. Vt. Stat. Ann. tit. 18, § 9708 (c).
140. Ind. H. B. 1114 (2012);
141. Ky. S. B. 217, 2012 Leg., Reg. Sess. (2012);
142. Wyo H. B. 75, 61st Leg., Budget Sess. (2012).
143. Wash. H. B. 2462 (2012).
144. Ohio H. B. 241, 128th Gen. Assembly (2009);
145. Ohio H. B. 601, 127th Gen. Assembly (2008).
146. Midwest Care Alliance, "Networks and Task F orces", http://www.oh pco.org/aws/MCA/pt/sp/networks, accessed 10 December 2012;
147. Midwest Care Alliance, see note 55 above.
148. Tennessee authorizes the development and use of "universal do-not-resuscitate orders", which the statute defines as "a written order that applies regardless of the treatment setting and that is signed by the patient's physician that states that in the event the patient suffers cardiac or respiratory arrest, cardiopulmonary resuscitation should not be attempted." Tenn. Code Ann. § 68-11-224 (e) (6). An opinion of the attorney general interpreted this statute to permit the Board for Licensing Health Facilities to promulgate a POST form, which addresses life-sustaining treatments that go beyond CPR. See Sabatino, note 3 above, pp. 47-8 (citing Atty. Gen. Op. No. 05-093, 13 June 2005).
149. Tenn. Comp. R. and Regs. 1200-08-01-.13 & -.15; 1200-08-06-.13 & -.15; 1200-08-10-.13 & -.15 (2012).
150. 16 Del. Admin. Code 4304-1.0-14.0 (2012) (adopted 2012).
151. Letter from K. T. Rattay, Director, Division of Public Health, Delaware Department of Health and Social Services (14 November 2012), http://www.medsocdel.org/Portals/1/In %20the%20News/ MOLST%20Form%20Letter%20111412.pdf, accessed 10 December 2012.
152. Ore. Admin. R. § 847-035-0030 (6) (2012).
153. Chicago End-of-Life Care Coalition, "IDPH Uniform DNR Advance Directive and the Evolution of POLST Illinois", http://www.cecc.info/ resourcelinks/physicians-order-for-life-sustaining-treatmentpolst, accessed 10 December 2012;
154. New Jersey Hospital Association, "DHSS Selects NJHA to Lead New Jersey's POLST Initiative", http://www.njha.com/html/DailyMessage.aspx?id= 13733, accessed 10 December 2012;
155. "10.01.21 Medical Orders for Life-Sustaining Treatment (MOLST) Form-Procedures and Requirements", Maryland Register 39, no 16 (10 Aug. 2012);
156. Maryland MOLST, http://marylandmolst.org/pages/molst-form.htm, accessed 10 December 2012.
157. Iowa Dept, of Pub. Health, "IPOST Form and Guidance", http://www.idph.state.ia.us/IDPH ChannelsService/file.ashx?file=lEC05976-26El- 4950-B60B-02CABD2A4A66 (25 June 2012);
158. http://www.idph.state.ia.us/IDPHChannelsService/file.ash x?file=4162F2B4-7E54-4717-B5EA-F3F60A72C6DF, accessed 10 December 2012.
159. These websites contain guidelines and supplemental materials to facilitate POLST implementation: http://www.wvendoflife.org/POLST, accessed 10 December 2012;
160. http://www.compassion an dsupport.org/index.php/for-patients-families/ moist, accessed 10 December 2012;
161. http://www.capolst.org/, accessed 10 December 2012;
162. http://www.wsma.org/POLST, accessed 10 December 2012;
163. http://kokuamau.org/polst, accessed 10 December 2012.
164. POLST is well-established in Lacrosse, Wisconsin, but not in the rest of the state. Unfortunately, the Wisconsin Medical Society decided not to include POLST in a statewide program to encourage advance care planning. In light of opposition from Roman Catholic bishops in the state, the Medical Society determined that POLST is too much of a "lightning rod." A. Johnson, "End-of-Life Medical Care Initiative Prompts Worries about Abuse", Milwaukee Sentinel-Journal (17 October 2012).
165. Hospice of the Bluegrass, "Kentuckians Deserve the MOST", http://www.hospicebg.org/most.html, accessed 10 December 2012;
166. J. Ard, "Rule Making or Legislation: Test Cases from Health Care", State Bar of Michigan Administrative Law Journal 35(2009):2-7;
167. J. Wilson, "End-of-Life Wishes", Columbus Telegram, 25 March 2005;
168. Nevada Center for Ethics and Health Policy, "An Introduction to the Nevada SMOST", http://www.unr.edu/ncehp/spost-summary.html, accessed 10 December 2012.
169. Center for Practical Bioethics, "Transportable Physician Orders for Patient Preferences (TPOPP)", http://www.practicalbioethics.org/ initiatives/transportable-physician-orders.html, accessed 10 December 2012;
170. "Program Description for: Minnesota", http://www.ohsu.edu/ polst/programs/documents/MNProgramDescription.pdf (11 March 2010);
171. "Program Description for: Maine", http://www.ohsu.edu/polst/ programs/documents/MaineDeveloping ProgramDescription-INFO-ldocmmc2011.pdf (7 July 2011);
172. Maine Hospice Council, http://maine hospicecouncil.org/polst/, accessed 10 December 2012;
173. "Program Description for: North Dakota", http://www.ohsu.edu/ polst/programs/documen ts/NDProgramDescription.pdf (30 December 2008).
174. Center for Health Care Ethics, Oregon Health and Science University, "History of the POLST Paradigm Initiative", http://www.ohsu.edu/polst/ developing/history.htm, accessed 10 December 2012.
175. Minnesota Medical Association, "POLST Communications" http://www.mnmed.org/KeyIssues/POLSTCommunications/tabid/3291/Default.aspx, accessed 10 December 2012;
176. L. Vawter and E. Ratner, "The Need for POLST: Minnesota's Initiative", Minnesota Medicine 93, no. 1(2010):42-46, http://www. minnesotamedicine.com/Current Issue/ClinicalRatnerJan2010/tabid/3294/Default. aspx.
177. "Program Description for: Maine", http://www.ohsu.edu/polst/ programs/documents/MaineDevelopingProgramDescription-INFO-1docmmc2011.pdf (7 July 2011).
178. "Program Description for: New York", http://www.ohsu.edu/polst/ programs/documents/NYProgramDescription082908FINAL.pdf (29 Aug. 2008).
179. See Sabatino, note 3 above, pp. 45-6. P. A. Bomba and C. P. Sabatino, "POLST: An Emerging Model for End-of-Life Planning", Elder Law Report 50, no. 7(2009):1-5;
180. D. Meier and L. Beresford, "POLST Offers Next Stage in Honoring Patient Preferences", Journal of Palliative Medicine 12, no. 4(2009):291-295.
181. Iowa H. F. 2165, codified at Iowa Code Ann. § 144D. 1-.4.
182. "IPOST: The Report of the Patient Autonomy in Health Care Decisions Pilot Project", (2010), https://idph.state.ia.us/IPOST/Resources. aspx, accessed 10 December 2012.
183. See Center for Health Care Ethics, Oregon Health and Science University, "Program Requirements", http://www.ohsu.edu/polst/developing/core- requirements.htm (26 April 2012) (specifying that the treatment preferences communicated by a POLST form "required a medical order that needs signature by a health care professional").
184. Cal. Prob. Code § 4780 (c);
185. "Georgia POLST Form", http://www.dph.ga.gov/POLST/, accessed 10 December 2012;
186. Haw. Rev. Stat. Ann. § 327K-1, K-2;
187. Illinois Department of Public Health (IDPH), "Uniform Do-Not-Resuscitate (DNR) Advance Directive: Guidance for Health-Care Providers and Professionals", www.idph.state.il.us/public/books/guide-hcpp. htm, accessed 10 December 2012;
188. "Transportable Physician Orders for Patient Preferences (TPOPP)", http://www.practicalbioethics.org/initiatives/transportable- physician-orders.html, accessed 10 December 2012 (Kansas and Missouri);
189. Nevada Center for Ethics and Health Policy, "An Introduction to the Nevada SMOST", http://www.unr.edu/ncehp/spost-summary.html, accessed 10 December 2012;
190. N. Y. Pub. Health Code § 2994dd;
191. Tenn. Code Ann. § 68-11-224. W. Va. Code Ann. § 16-30-25.
192. Colo. Rev. Stat. Ann. § 15-18. 7-104;
193. Idaho Code Ann. § 39-4512A (1);
194. Iowa Code Ann. § 144D.2 (c);
195. Massachusetts Dept, of Publ. Health, "Circular Letter DHCQ 12-3-560", http://www.mohtma.org/sites/molst-ma.org/files/DHCQ-560.pdf (20 March 2012);
196. Minn. Med. Assn, "FAQ: The POLST Form", http://www.mnmed.org/ LinkClick.aspx?fileticket=FGvy4%2f9lbco%3dandtabid=3291 (January 2010);
197. Montana Board of Medical Examiners, "POLST", http://bsd.dli.mt.gov/license/bsd-boards/med-board/polst.asp, accessed 10 December 2012;
198. N. C. Gen. Stat. Ann. § 90-21. 17 (c);
199. N. J. Stat. Ann. § 26:2H-134;
200. Ore. Admin. R. § 333-270-0030;
201. Ore. Rev. Stat. § 127. 663 (6);
202. R. I. Gen. Laws §§ 23-4.11-2(12), 23-4.11-3.1 (d) (1);
203. Utah Code Ann. § 75-2a-106 (2);
204. Vt. Stat. Ann., tit. 18 §§ 9701 (5) and 9708 (d);
205. Washington State Medical Association, "POLST", http://www.wsma.org/POLST, accessed 10 December 2012.
206. "Program Description for: Alaska", http://www.ohsu.edu/polst/ programs/documents/AKProgramDescription.pdf, accessed 5 December 2012.
207. S. C. Zweig, L. L. Popejoy, D. Parker-Oliver and S. E. Meadows, "The Physician's Role in Patients' Nursing Home Care", Journal of the American Medical Association 306, no. 13(2011):1468-1478;
208. J. L. Meyers et al., "Physician Orders for Life-Sustaining Treatment Form: Honoring End-of-Life Directives for Nursing Home Residents", Journal of Gerontological Nursing 30, no. 9(2004):37-46.
209. California Advocates for Nursing Home Reform, "Physician Orders for Life Sustaining Treatment: Problems and Recommendations" (2010), 3, 6.
210. Coalition for Compassionate Care of California, "California POLST Form", http://www.capolst.org/, accessed 10 December 2012;
211. Kokua Mau, "Hawaii POLST Form", http://www.kokuamau.org/ professionals/polst, accessed 10 December 2012;
212. Iowa Dept, of Pub. Health, "IPOST Form", http://www.idph.state. ia.us/IPOST/Form. aspx, accessed 10 December 2012;
213. Minn. Med. Ass'n, "FAQ: The POLST Form", http://www.mnmed.org/ LinkClick.aspx?fileticket=FGvy4%2f9lbco%3dandtabid=3291, accessed 10 December 2012;
214. North Carolina Medical Society, "Using the MOST Form-Guidance for Healthcare Professionals", http://www.ncmedsoc.org/pages/public-health- info/end-of-life.html, accessed 10 December 2012;
215. Utah Commission on Aging, "POLST: Utah Physician Order for Life-Sustaining Treatment: A Life With Dignity Order", http://health.utah. gov/hflcra/forms/POLST/AdvanceDirectiveProviderGuide2011.pdf, accessed 10 December 2012. While facilitators arguably do an even better job than physicians, their role remains controversial.
216. Center for Health Care Ethics, Oregon Health and Science University, "Program Requirements", http://www.ohsu.edu/polst/developing/core- requirements.htm (26 April 2012).
217. "Upholding the Dignity of Human Life: A Pastoral Statement on POLST from the Catholic Bishops of Wisconsin", (July 2012), http://Wisconsin Catholic.org, accessed 15 December 2012;
218. E. C. Brugger, "A Critique of Colorado's New MOST Legislation", Linacre Quarterly 78, no. 2(2011):58-61.
219. But other Roman Catholic thought leaders more strongly support POLST. R. Hamel, "POLST under Fire", Healthcare Ethics USA 20, no. 1(2012):30-5;
220. G. D. Coleman and M. R. McLean, "POLST Supports Care in Context of ERDs", Health Progress 93, no. 6(2012):58-65.
221. Montana Board of Medical Examiners, "Using the Montana POLST Form: Guidance for Healthcare Professionals", http://bsd.dli.mt.gov/license/bsd- boards/med-board/polst. asp (30 June 2011).
222. 18 Vt. Stat. Ann. § 9708 (d) (3) (A) - (B).
223. Cal. Prob. Code § 4675.
224. B. J. Hammes et al., "The POLST Program: A Retrospective Review of the Demographics of Use and Outcomes in One Community Where Advance Directives Are Prevalent", Journal of Palliative Medicine 15, no. 1(2012):1-9.
225. T. M. Pope, "Legal Fundamentals of Surrogate Decision Maldng", Chest 141, no. 4(2012):1074-81;
226. T. M. Pope, "Comparing the FHCDA to Surrogate Decision Making Laws in Other States", NYSBA Health Law Journal 16, no. 1(2011):107-11.
227. Vermont is seeking to resolve uncertainty by directing the Department of Health to promulgate rules on the authority of non-agent, non-guardian decision makers. Vt. H. 201(2011), enacted as 2011 Vt.
228. Act 60, codified at Vt. Stat. Ann. § 9708.
229. S. E. Hickman et al., "The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the POLST Form", Journal of the American Geriatrics Society 59, no. 11(2011):2091-9.
230. Tennessee End-of-Life Partnership, "POLST and Surrogate Information", http://endoflifecaretn. org/information-about-post-and- appointment-of-asurrogate/, accessed 10 December 2012.
231. N. J. Stat. Ann. § 26:2H-135.
232. R. I. Gen. Laws §§ 23-4.11-2 (12) and 23-4.11-3.1 (d) (1).
233. 16 Del. Admin. Code § 4304-7. 2.
234. N. Y. Pub. Health L. § 2994-b;
235. Utah Code Ann. § 75-2a-106 (4).
236. See, e.g., Idaho Code Ann. § 39-4512A (2);
237. N. C. Gen. Stat. Ann. § 90-21.17;
238. Utah Code Ann. § 75-2a-106 (7).
239. See, e.g., Iowa Code Ann. § 144D.4 (1) - (3) (a POST form shall not supersede a Declaration Relating to Use of Life-Sustaining Procedures, durable power of attorney for healthcare, or an out-of-hospital DNR order)
240. Md. Code Ann., Health-Gen. § 5-608. 1 (c) (3) (ii) ("the 'Medical Orders for Life-Sustaining Treatment' form shall be consistent with [...] any known advance directive of the patient if the patient is incapable of making an informed decision. ");
241. W. Va. Code § 16-20-5 (b).
242. See, e.g., Cal. Prob. Code § 4781. 4;
243. Colo. Rev. Stat. Ann. § 15-18. 7-110;
244. Ind. H. B. 1114 (2012);
245. N. J. Stat. Ann. § 26:2H-135.
246. See, e.g., N. Y. Pub. Health Code § 2994-d (4) - (5) (the conflict issue is not expressly addressed, but surrogates are obligated to follow patient's known wishes, followed by patient's best interests, with additional preconditions for decision making related to end-of-life care listed in subsection 5-thus, a surrogate-completed POLST may not trump a patientcompleted advance directive except under certain conditions). Minnesota, Hawaii, Oregon, Vermont have not expressly addressed the issue. See Sabatino, note 3 above, pp. 30, 35.
247. Cal. Prob. Code §§ 4780 (c) and 4781.4 (West 2012). The danger is substantially mitigated by two features of healthcare decisions laws. First, surrogates must make treatment decisions consistent with the patient's preferences and best interests. Second, healthcare providers face liability for complying with surrogate decisions that they know deviate from this standard. See Pope, note 130 above.
248. Colo. Rev. Stat. Ann. § 15-18.7-110 (specifying that the most recent document controls in the event of a conflict between POLST and a prior health are directive, but with the qualification that a surrogate, advanced practice nurse, or physician assistant may not revoke prior healthcare/CPR directive that was completed by the patient).
249. N. J. Stat. Ann. § 26:2H-135 (specifying that the "more recent directive from the patient" will be honored in the event of conflicting healthcare instructions).
250. VHA Handbook 1004. 04 § (5) (b) (2) (a).
251. 42 U. S. C. § 1395CC (f) (1);
252. C. F. R. §§ 482. 13 (a) and 489.102 (a).
253. Md. Code Ann., Health-Gen. § 5-608. 1 (c) (1) (11) (1) - (2).
254. Utah Admin. Code § 432-31-4 (2) (b) - (c).
255. E. K. Fromme et al., "POLST Registry Do-Not-Resuscitate Orders and Other Treatment Preferences", Journal of the American Medical Association 307, no. 1(2012):34-5;
256. S. E. Hickman et al., "A Comparison of Methods of Communicating Treatment Preferences in Nursing Facilities: Traditional Practices versus the POLST", Journal of the American Geriatrics Society 58, no. 7(2010):1241-8;
257. S. E. Hickman, S. W. Tolle, K. Brunnelswitch, and M. M. Carley, "Use of a POLST Program in Oregon Nursing Facilities", Journal of the American Geriatrics Society 52, no. 9(2004):1424-9.
258. See Center for Health Care Ethics, Oregon Health and Science University, "Program Requirements", http://www.ohsu.edu/polst/developing/core- requirements.htm (26 April 2012) (requirement number 7 for endorsed programs specifies that "Completion of the form and the decisions recorded on it should be voluntary and based on shared medical decision making").
259. See Sabatino, note 3 above, p. 18.
260. Iowa Code Ann. § 144D.4 (6);
261. Colo. Rev. Stat. Ann. § 15-18. 7-108.
262. Idaho Code Ann. § 39-4514 (8) (a) - (b);
263. La. Rev. Stat. Ann. § 1299. 64.1 (B) (2);
264. Ore. Rev. Stat. § 127. 672;
265. Vt. Stat. Ann. tit. 18 § 9709 (e).
266. N. C. Gen. Stat. Ann. § 90-21. 17 (c).
267. R. I. Gen. Laws § 23-4. 11-3.1 (h).
268. 42 C. F. R. § 489. 102 (a) (3) ("Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive.").
269. Cal. Prob. Code § 4677 ("A health care provider, health care service plan, health care institution, disability insurer, self-insured employee welfare plan, or nonprofit hospital plan or a similar insurance plan may not require or prohibit the execution or revocation of an advance health care directive as a condition for providing health care, admission to a facility, or furnishing insurance.").
270. See, e.g., Cal. Prob. Code § 4781. 2;
271. Colo. Rev. Stat. Ann. §15-18. 7-104 (1) (a);
272. Haw. Rev. Stat. Ann. § 327K-2;
273. Idaho Code Ann. §§ 39-4512B and 39-4513 (5);
274. Iowa Code Ann. § 144D. 3 (5) (specifies that health care providers unwilling to comply with POLST orders on policy/religious beliefs/moral convictions shall take all reasonable steps to transfer patient);
275. Md. Code Ann., Health-Gen § 5-608. 1 (f);
276. N. J. Stat. Ann. §§ 26:2H-134 (a) and 139;
277. Ore. Admin. R. 847-010-0110;
278. R. I. Gen. Laws § 23-4. 11-3.1 (c) (1);
279. W. Va. Code Ann. §§ 16-30-12, 16-30-10, 16-30C-7.165;
280. T. M. Pope, "Legal Briefing: Conscience Clauses and Conscientious Refusal", The Journal of Clinical Ethics 21, no. 2(2010):163-80.
281. E.g., Colo. Rev. Stat. Ann. § 15-18. 7-104 (l) (b);
282. Iowa Code Ann. § 144D. 3 (2);
283. Md. Code Ann., Health-Gen § 5-608. 1 (f).
284. E.g., Colo. Rev. Stat. Ann. § 15-18. 7-104;
285. N. J. Stat. Ann. § 26:2H-134 (c).
286. N. C. Gen. Stat. § 90-21.17 (d);
287. A 2004 Oregon study found that 25 percent of surveyed EMTs reported difficulty locating a POLST form the last time they treated a patient with a POLST. T. A. Schmidt, S. E. Hickman, S. W. Tolle, and H. S. Brooks, "The Physicians Orders for Life-Sustaining Treatment Program: Oregon Emergency Medical Technicians' Practical Experiences", Journal of the American Geriatrics Society 52, no. 9(2004):1430-4, 1432. (Pubitemid 39209588)
288. Ore. Rev. Stat. Ann. § 127. 663-.681.
289. Oregon POLST Registry, "Nov. 2012 Monthly Update", http://public.health.oregon. gov/Provider PartnerResources/EMSTraumaSystems/ Physician OrdersforLifeSustainingTreatment/Pages/index. aspx, accessed 15 December 2012.
290. Or. Rev. Stat. Ann. § 127. 663-.681;
291. Mont. Code Ann. § 50-9-501;
292. Montana DOI, "End of Life Registry and Advance Health Care Directives", https://doi.mt.gov/consumer/end-of-liferegistry/, accessed 10 December 2012;
293. Vermont Dept, of Health, "Vermont Advance Directive Registry", http://healthvermont.gov/vadr, accessed 10 December 2012.
294. Mich. S. B. 723(2012), enacted as 2012 Mich. Pub. L. No. 179.
295. DHHS, Office of the National Coordinator for Health Information Technology, "HealthIT.hhs.gov Information Related to the American Recovery and Reinvestment Act of 2009", http://healthit.hhs.gov/portal/server.pt/ community/healthit-hhs-gov-learn-about-hitech/1233 (21 June 2012).
296. H. R. 3590, § 1233, 111th Cong. (2009).
297. DHHS, "Medicare Program: Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2011", 75 Fed. Reg. 73, 170 (29 November 2010).
298. R. Pear, "U. S. Alters Rule on Paying for End of-Life Planning", New York Times, 4 January 2011;
299. DHHS, "Medicare Program: Amendment to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2011", 76 Fed. Reg. 1366 (10 January 2011).
300. H. R. 1589, 112th Cong., 1st Sess. (2011).
301. 38 C. F. R. § 17. 32.
302. VHA Handbook § 1004. 04 (25 October 2012).
303. R. K. P. Chang et al., "Sowing Seeds and Building Collaborations: Challenges Faced and Learning Points on Starting Systemic Advance Care Planning in a Hospital in Singapore", BMJSupportive and Palliative Tertiary Care 2, no. 2(2012):201-2.
304. J. In der Schmitten et al., "A Complex Regional Intervention to Implement Advance Care Planning in One Town's Nursing Homes: Protocol of a Controlled Inter-Regional Study", BMC Health Services Research 11, no. 14(2011):1-9;
305. C. H. Wiese et al., "[The Gottingen Palliative Emergency Card: Improvement of Emergency Medical Care for Ambulatory Palliative Care Patients: The "Yellow Card for Rescue Services]", Deutsche Medizinische Wochenschrift [German Medical Weekly] 133, no. 18(2008):972-6. (Pubitemid 351828936)
306. Health Canada, "Implementation Guide to Advance Care Planning in Canada: A Case Study of Two Health Authorities" (2008), hc.sc.gc.ca/hcc.sss/pubs/palliat/2008-ace-guide-eesl/index-eng.php, accessed 15 December 2012.
307. Fraser Health, "Policy: Medical Orders for Scope of Treatment (MOST) and Advance Care Planning (ACP) " (13 June 2012); email from Doris Barwich to Thaddeus Pope, 4 December 2012.
308. Alberta Health Services, "Advance Care Planning and Goals of Care Resources", http//www.albertahealthservices.ca/3917.asp, accessed 10 December 2012.
309. Regina Qu'Appelle Health Region, "About Advance Care Planning", http://www.rqhealth.ca/programs/advanced-care-planning/index.shtml, accessed 10 December 2012.
310. Queensland Health, "Resuscitation Planning", http://apps.health.qld.gov. au/acp/Public-Section/Resuscitation-Planning/ resuscitation Planning3.aspx, accessed 10 December 2012.
311. In re Barnes, No. 27-GC-PR-111-16 (Hennepin County Probate Ct., Minn., 4 February 2011).
312. Krela v. Kryla, No. 6:12-CV-01089-TC (D. Ore., filed 18 January 2012).
313. Scottrade v. Davenport, No. 90-CV-11-3-BLG-RFC, 2012 WL 2019679 (D. Mont., 5 June 2012).
314. Costello v. University of Washington Medical Center, No. 11-2-15367-3 SEA (King County Sup. Ct., Wash. 2011) (Order granting defendant's motion to dismiss), affirmed, No. 67840 (Wash. App., 24 September 2012).
315. CDPH, Licensing and Certification Division, "Statement of Deficiencies and Plan of Correction, Survey of Cresthaven Nursing Home, No. CA-070000038" (22 December 2009).