I was recently speaking to my friend and colleague, Ronnie Genser of Bereavement Navigators. She asked if I was familiar with “POLST.”
I told her that I wasn’t.
Over the next 5-10 minutes, Ronnie explained what a POLST is and why everyone should consider putting one in place.
I found the information so interesting – and important – that I asked Ronnie to spend some time with me on another phone call so I could record our discussion and share it with you. Below is a recording and transcript of a call between Ronnie and myself on September 30, 2014.
Hit play on the media player below to listen to our conversation. It runs about 30 minutes long.
I’ve also included a transcript of our conversation below the media player.
Russ: Hey, this is Russ Thornton with Wealthcare for Women. Today, I am excited to be talking to a friend, Ronnie Genser. Ronnie owns and operates an organization here in the Atlanta area called Bereavement Navigators. Ronnie and I were first introduced some time ago – it’s probably been a little over a year ago – by a mutual acquaintance, and I’ve really enjoyed getting to know her and keep in touch. We had a conversation a couple of weeks ago about a specific topic that Ronnie enlightened me on and that we wanted to talk a little bit about and share with you today.
Before we get into that, Ronnie, why don’t you say hello and tell us a little bit about who you are and what you’re working on these days.
Ronnie: Thanks, Russ. I really appreciate it. Before I do that, though, let me give some background on who I am so our audience knows a little about me and where I’m coming from, and then the topic perhaps will make a little more sense.
I want to share with our audience the fact that three years ago, October 8, a few days from now, my husband died unexpectedly from complications of a heart attack which he suffered nine days previous to that. He was sixty-one years old. I was two years older than he was, so, as I call myself, an unexpected, relatively young widow. Prior to this, I had a long career in domestic and international sales and marketing.
Having to deal with all the things I needed to deal with after his death really surprised me. I call them the numerous and unexpected tasks. The things I needed to learn to organize these tasks, the resources I found, and the tips that I learned, I then realized might be useful to other people in their journeys after the death of a spouse, partner, or a loved one. Now, I share my work as what’s called a bereavement navigator. The name of the business is also Bereavement Navigators, plural. I share that with other widows, widowers, adult children, relatives, et cetera who have lost a loved one in hopes that my knowledge, the things that obviously they didn’t prepare us for in high school, as I call it, will make this process and their journey ahead easier.
Then over the course of the last couple of years, I’ve come to realize that had I been better prepared, and I’m not talking psychologically but prepared in terms of the tasks and things that would face me, that the after-death issues would have been far less time-consuming, stressful, frustrating, et cetera. Now, I also work with what I call healthy people, couples and individuals, to better prepare them in their affairs before their own death, especially all the things that are outside their professional service advisors. Hopefully, that work makes what they have to face after a death much easier, less time-consuming and, more importantly, less stressful.
Today, what I really want to talk about and how this came about, is I want to talk about what’s called the POLST, a document that many people don’t know about. POLST, “P-O-L-S-T,” stands for Physicians Orders for Life-Sustaining Treatment. It’s a relatively new document. I’m going to talk about it in more depth in a few minutes. It wasn’t around at the time when my husband died three years ago. It was about a year later that it became law in the State of Georgia. I’m talking to everyone today as a widow who basically had to make what I call the ultimate decision about my husband when they told me that there was no more that they could do for him and what did I want to do.
Many of us have Advanced Health Care Directives, but they’re not as detailed as this new document, the POLST. I want to talk a little bit about that because I really believe that if people were aware of this document, again, it would decrease stress, concern, potential guilt after the death of their loved one. Fortunately, in my case, even though the POLST wasn’t around, my husband and I not only had Advanced Directives, but we had talked many times about what we’d want should something happen to either one of us.
It was the greatest gift that he could have given me because what I came to realize was even though I was appropriately sad, and at times continue to be sad about his death, I had no regrets, no guilt. What I realized was I was really carrying out his wishes, which is what I knew. By completing a POLST, one is able to know in their heart, which is the most important thing. Know in your heart, not only on the piece of paper, but in your heart what your loved one would want.
I think with that, I’d like to start off with a few statistics about where the population is in terms of knowing about what people want and how many have even created Advanced Directives, let alone a POLST. I think I’ll go through a few of those statistics and then go into talking about the POLST document itself, what it consists of, the how, who, when, why, and some other things about it and finally, some differences about the POLST and the Advanced Directive.
Russ: Before you do that, Ronnie, and I’m looking forward to you sharing your experience and what you’ve learned about the POLST and why you think it’s important, but you mentioned a couple of times an Advanced Directive. While you and I are familiar with that term, some of our listeners may not. Some of you listening to this may be more familiar with the idea of a Living Will, which sets forth end-of-life decisions and things like that. In Georgia, it’s referred to as an Advanced Directive. There can be some differences, but you can generally think of those two terms synonymously, so if Ronnie or I mention an Advanced Directive, we’re thinking, at least in concept, of something similar to a Living Will.
Ronnie: Right. Today, the formal name, I think, is Advanced Directive for Health Care in the State of Georgia. Each state has different terms of how they call their advanced directive. There are different ways. Today, I want to be really clear, I personally am just talking about the State of Georgia.
Russ: Right. Ronnie and I were speaking a couple of weeks ago and we were catching up, and I was, “Tell me what you’ve been up to.” And she was, “Have you heard of a POLST?” I had to admit I had not. We got into this conversation which ultimately led to the call we’re having right now because based on what Ronnie had shared with me, (a) I found it very interesting, (b) I think it’s important information, as she’s already alluded to and will continue to cover, that more people need to be aware of, as it is a relatively new document that’s available for your estate planning and planning for the care of loved ones.
With that, Ronnie, I think you said you were going to start with some statistics, so I’ll let you jump into that.
Ronnie: Thanks, Russ. Some things that I’ve learned over the last couple of years as I’ve also researched this topic some more, as I wanted to learn more and fill out my own POLST. First of all, people’s wishes about where they want to die. Less than ten percent of elderly Americans say they want to die in a hospital, yet approximately four times that number do die in a hospital.
Creation of the Advanced Directive for Health Care. Today, only eighteen to thirty-five percent of the adult population has even created an Advanced Directive for Health Care, and even a smaller number, a very small number, has discussed POLST with their doctor. In addition, less than thirty percent have had a conversation with their loved ones about their wishes. This, to me, as I said before, to me is just so important to give you peace going forward should you be confronted with having to make what I call the ultimate decision.
A couple of other quick statistics are sixty percent of people say that making sure their family is not burdened by tough decisions is extremely important, whereas fifty-six percent have not communicated their end-of-life wishes, so it’s important to make sure your family is not burdened if you haven’t communicated your wishes.
Two more statistics. Eighty percent of people say that if seriously ill, they would want to talk to their doctor about end-of-life care, whereas only seven percent report having had an end-of-life conversation with their doctor. One of the things that the POLST will do for you is the only way you can have a valid POLST is to have it signed by your doctor. It’s not signed by your attorney; it’s signed by your doctor. The doctor will only sign it if you have a conversation with them.
Lastly, eighty-two percent of people say it’s important to put their wishes in writing, whereas only twenty-three percent have actually done it. There’s lots of work to be done here.
The bulk of what I really want to talk about today is the actual document itself. Again, the POLST stands for Physicians Orders for Life-Sustaining Treatment. The definition of this is it’s a medical order. Understand that it’s not a legal document. It’s a medically recognized order that aims to enable seriously ill patients to designate the treatments – treatments plural – they want and to ensure that those preferences are honored by medical professionals. We’re going to get into a little bit more of that when we talk about the differences between an Advanced Directive and a POLST.
The current version of the POLST was legalized by the Georgia Department of Public Health in 2012. It’s a law based on Georgia Code Section 29-4-18(I). The POLST form, however, was initially used in Georgia in 2007 in the WellStar Health System, and its use began to grow independently in isolated hospitals throughout the state, meaning just pockets here and there. In an effort to promote the form statewide, the WellStar Health System collaborated with a non-profit organization called the Georgia Health Decisions to work towards legislative support of the form, meaning legalizing the form.
The Georgia Health Decisions was founded by Dr. Richard Cohen, who is now Chairman of their Board of Trustees. He’s also the Medical Director of the Ethics Program at WellStar Health System here in Atlanta. Prior to that, he was an orthopedic surgeon specializing in total joint replacement. Richard Cohen is probably the leading advocate for the Georgia POLST.
Again, in 2012, the Department of Public Health made available what’s now the legally recognized POLST form used in Georgia. You can see that by going to www.gaPOLST.org. You can download a copy of it there for your own use. I highly recommend going to that website. There’s pretty much everything you want to know about a POLST. You can take it to your doctor; you can think about it; you can check if off. We’ll talk about that in a minute. Check off the things you want and have your doctor sign it.
There’s an organization called the Georgia POLST Collaborative. It consists of thirty statewide organizations, and it was formed right after the law was in place to promote POLST usage. It does that promoting it through healthcare professionals and institutions across the state and by educating Georgians about advanced care planning, just having this conversation, making your wishes known, and the role of the POLST as a vehicle to make your wishes known. Georgia, just as an aside, became the sixteenth state in the nation to have a POLST program endorsed by the National POLST Paradigm.
The vision for the POLST is that all Georgians will have their healthcare preferences known and honored. That’s obviously the goal. And the mission is to improve healthcare at the end of life so that people have the kind of quality they want at the end of life and what we call a good death that they would want for themselves, whatever that is.
What I’d like to do now is to go over a few of the sections and explain what this POLST form looks like and how relatively easy in terms of checking boxes. It may be more difficult in terms of thinking through your decisions, but easy in terms of boxes to fill it out. When you go to georgiapolst.org, you’ll see down at the bottom of the page a place to click on the form and download it. It’s two pages. Basically, the form itself is one page; the second page is more instructions. On that first page besides your name, the last four digits of your Social Security number, your date of birth, and your gender, there are five sections, and they’re short. There’s five sections, A through E.
Section A is about cardiopulmonary resuscitation, or CPR. If you have no pulse and you’re not breathing, what do you want? Do you want to attempt resuscitation, meaning CPR? Or do you want what’s called AND, allow natural death, do not attempt resuscitation? That’s the choices, basically choices. The only other choice is do you want resuscitation orders to remain in effect during any surgical or invasive procedures?
Section 2, or Section B, is called Medical Interventions, when you have a pulse and you’re breathing. Do you want comfort measures, limited additional intervention, additional treatment, which could include comfort measures, or limited additional interventions such as lab tests, blood products, dialysis, et cetera? Or go to a hospital if you’re not in a hospital? Do you want full treatment, which includes the additional treatment and incubation, mechanical ventilation and cardioversion, and intensive care? There’s a place even to add additional orders. It really starts from the simplest type of medical intervention and goes through more extensive type of medical intervention, the lowest to highest type of intervention.
Section C is about antibiotics to relieve symptoms. The choices there are: no antibiotics; determine use or limitation of antibiotics when infection occurs; use antibiotics if life can be prolonged; and, again, additional orders, which is a place where one can fill in their own specialized requests, so pretty nice.
Section D, the fourth section, is Artificially Administered Nutrition or Fluids. It says where indicated, always offer food or liquids by mouth if feasible. You can check if you don’t want anything, which is no artificial nutrition by tube, and you can check no IV fluids. You can also check a defined trial period of artificial nutrition. You can check long-term artificial nutrition by tube, and, again, additional orders. Going from simplest to more involved, the same as with fluids, going from no IV fluids to a defined trial of IV fluid and long-term IV fluids as well as additional orders.
Lastly, the last section, Section E, is the Reason for the Orders and the Signatures. It just says, “To the best of my knowledge, these orders are consistent with the patient’s current medical condition and preferences as indicated by:” When it says “best of my knowledge,” it’s because this is signed by a physician. It is also signed by the person who it is for, but it’s only valid when it’s signed by the physician. The choices there are, I’ve discussed it with the patient, meaning the doctor has discussed it; they’ve reviewed it via the patient’s Advance Directive. They’ve discussed it with the patient’s authorized representative; that means when the patient is typically unable to discuss it themselves. Or by verbal consent was given for an allow natural death order.
This is much, much, much more detailed than an Advanced Directive. It really is such that everybody from the medical community knows what you want, knows how to act, knows what should be done at end of life. Then at the bottom, it’s signed by the physician; it’s signed, if possible, by you or your representative. And dated, phone numbers, things like that.
In terms of making decisions, the options are all out there for you, but you’re also given lots of places to write in whatever you want so that you can have exactly what you want, which is not as detailed as the Advanced Directive.
Russ: Ronnie, based on what you’ve shared so far, it seems like this is an important document and that everyone should at least review it, consider it, and likely put one in force. Maybe you’ll touch on this in a moment, but is there a situation that you can think of or that you’ve encountered where someone might not want to have a POLST in place?
Ronnie: From my personal experience, because that’s the only place I’m coming from, from my personal experience, no. When I just saw this, I thought, wow, this is really clear. If somebody has a POLST, there’s no question about what they want. There’s no Should we have done this? Would Mother have wanted this? Would my spouse have wanted whatever? How do I make this decision? There’s no conflict. It’s just so clear. So, no. In a minute, when I get to the differences between the POLST and Advanced Directive, I’ve created a chart, and we’ll talk some more about that.
Russ: Great. We’ve got about ten more minutes. I know you’ve got a lot to cover, so I’ll let you jump right back in.
Ronnie: Basically, what I’m going to do is- If people will think mentally of a two-column chart with Advanced Directive on the left and POLST on the right, I’m going to go through about six things that differentiate the two of them.
Before that, I want to talk about a question that people ask. Does the POLST form replace the Advanced Directive? The POLST form really complements the Advanced Directive. It’s not intended to replace it. An Advanced Directive is necessary to appoint a legal healthcare representative, someone who can speak for you, and to provide instructions for future life-sustaining treatments. The Advanced Directive is recommended for all adults, regardless of their health status. That’s a little bit of the focus or the direction of the Advanced Directive.
The POLST form should accompany an Advanced Directive where appropriate. It’s instantly activated. It’s not a kind of thing where you might have gone to your attorney to get it, although even with the Advanced Directive in this state you don’t have to have an attorney. It’s instantly activated, and it’s typically for people outside an acute care hospital versus a POLST is really more activated when someone is really in acute condition situation. It can be activated, obviously, in a hospital. In a minute we’ll also talk about where it can be activated, which to me is one of the most important things.
What are the differences between the Advanced Directive and the POLST? Basically, who is it for? The Advanced Directive is for anybody, typically 18 and older, whereas the POLST is for people who are seriously ill or frail at any age. Who completes the documents? An Advanced Directive is completed by the individual. The POLST is really completed by the physician and patient, meaning there is a discussion. I personally have taken a POLST and checked off what I wanted before discussing it with my physician. I’m not walking into the office trying to go over it with them, because I’ve given it some thought ahead of time, whereas some people may choose to say, okay, I’d like to just discuss it and get clearer on what all these things mean with my physician. You can do it either way, but the person who really needs to sign it in addition to the patient is the physician.
Again, who signs the Advanced Directive? An Advanced Directive is signed by an individual and two witnesses, but you don’t need an attorney or notary for an Advanced Directive. Some people think you do have to go to an attorney. The POLST is signed by a physician and either the patient or the patient’s authorized representative. If the patient is not able to sign, if they’re too ill, that patient’s authorized representative can sign.
What does each one really provide when you’re comparing them? The Advanced Directive provides general instructions for future treatment whereas the POLST provides specific medical orders for current treatment, and, therefore, it’s really instantly activated at the time that it’s needed. I want to talk about that. Sometimes it’s been said that a POLST should be created within twelve months of end of life. But who knows when end of life is? One could have been, god forbid, in a car wreck or something like that. I really try and encourage people to at least fill out with their physician the POLST at any time in their life. I think that if, god forbid, somebody had a car wreck, there may be major decisions to be made and if you don’t know what the answers are, it’s going to be very difficult and provide a great deal of stress.
The one thing, though, that is very different between an Advanced Directive and a POLST is the Advanced Directive does appoint a healthcare representative, or an authorized representative, somebody who can speak for you. The POLST doesn’t do that. The doctor is, in essence, when you think about it, because the doctor signs it, the doctor is speaking for you, and the document states that they have previously spoken with you. That’s the difference there.
Last two things are who is the Advanced Directive guiding and who is the POLST guiding? Who doesn’t it guide? The Advanced Directive does not guide emergency medical personnel, meaning if you’re in an ambulance, an Advanced Directive, if you’ve decided that if you’re not breathing and there’s no hope, that you don’t want to be revived. So EMTs in an ambulance, if there’s any possibility of your being able to be revived will start CPR. Versus if you have a POLST and it states that you allow natural death, and that seems to be an option because it’s of the state that you’re in, if you have a POLST with you at that time so you can show them, the EMTs will not revive a person. It’s a huge difference there.
Lastly, the Advanced Directive guides inpatient treatment decisions when it’s made available as well as the POLST does also guide inpatient treatment decisions when made available.
That’s basically the differences between the two.
Any questions, Russ?
Russ: First of all, thank you for sharing all that. I know you covered a lot in a relatively short amount of time and there’s clearly a lot more that goes into the decision-making and the considerations around the POLST as well as an Advanced Directive and other end-of-life and care decisions and things of that nature. As we begin to wrap up, my biggest question is if you, given all that you’ve just shared, if you had to give listeners one or two key takeaways about a POLST and its potential role in their care or the care of their loved ones, friends, family, what are the one or two key takeaways from this whole idea, this whole concept of a POLST?
Ronnie: I think the whole concept here is not only the document. It’s to think about what you want for your own end-of-life care, which is what the POLST is really doing by answering the questions. In addition to filling out the POLST with your doctor is to have the conversation with your loved ones and have your loved ones know that a POLST exists, where it is, if it’s on file with your doctor, if you have a copy of the signed form at home, wherever you live or where that is, with your documents, and that you have a conversation about all the things that you’ve checked so that they know in their hearts, should end of life be near, that they know what you want. They know that what’s happening due to a POLST is that your wishes, which you’ve thoroughly discussed, are being implemented. So (a) there’s less decisions for them to be made and even if they perhaps don’t agree with what you want, you are getting what you want. That I think are the biggest takeaways or what I want people to understand.
Russ: I agree. I think that’s important. To echo some of your opening comments, when you were talking about your own situation with your husband, when you were undergoing end-of-life decisions, clearly a document like a POLST is there to protect and maintain the wishes of the person in need. I think to your point, I think it also can serve an important role for that person’s survivors, as it can help prevent guilt, regret, second-guessing, that wondering, well, what if we had done this or I wonder if he or she had wanted me to do that. I agree. Clearly, we want to make sure of that.
Ronnie: It will also minimize family conflict. I didn’t talk about that. Totally minimize family conflict, because there’s no group decisions to be made. The person has made those decisions.
Russ: Yeah, absolutely.
Ronnie: With their doctor.
Russ: Ronnie, I know you mentioned earlier one website. Again, just for those that have been listening, I’m speaking with Ronnie Genser of Bereavement Navigators, and we’ve been talking about this POLST document, which stands for Physicians Orders for Life-Sustaining Treatment. Ronnie, what websites or resources can people go to to learn more about the POLST?
Ronnie: I’d say the simplest one and the easiest one and one of the most comprehensive is gaPOLST.org. There are some others. For example, there’s one at the Georgia Department of Health, but basically, when you go to the POLST section, it takes you to gapolst.org. I think that right now is the best for people in the state of Georgia.
Russ: Ronnie, for our listeners, if they would like to learn more about you and what you do or if they’d like to perhaps reach out to you, what’s the best way that people can find you or get in touch with you?
Ronnie: Two ways. My preference is by phone, because I find that one question leads to another and it’s usually a discussion, so by phone. Bereavement Navigators phone is 404-843-9460. Again, 404-843-9460. Or by e-mail.
Russ: Great. Before we wrap up, any final thoughts or comments, Ronnie?
Ronnie: I wish everybody a long and healthy life.
Russ: Thanks, Ronnie. I’m glad we were able to do this call. I really appreciate you sharing your wisdom and experience and what you’ve learned around this POLST as a planning document and as a tool that people can use to take care of loved ones, and, as you also mentioned, protect the interests of their survivors and things of that nature.
Again, I’m Russ Thornton. I’m with Wealthcare For Women. Thanks for joining us.
Ronnie: Thank you, Russ.
If you have any questions about a POLST and how it may play a role in your estate and end-of-life planning, please contact me and let me know. And if you’d like to speak with Ronnie, please contact her directly or reach out to me and I’ll be glad to put you in touch with her.
IMPORTANT UPDATE: As of Tuesday, October 14th, 2014, I’ve learned – thanks to an update from Ronnie Genser – that the Wellstar health system (in Georgia) is no longer currently accepting the POLST. There are some workarounds, but I recommend that you still have this discussion with your doctor and make sure have a clear understanding of how to make sure your wishes will be carried out in the manner you would like. It’s also a good idea to see if your POLST will be honored by the state where you reside and/or the healthcare institutions you utilize locally or while traveling. We’ll keep you posted as we learn more.
LATEST UPDATE FROM RONNIE GENSER:
As of November 26, 2014 from Dr. Richard Cohen, Chairman of their Board of Trustees of Georgia Health Decisions. He is also the founding chairman of the Georgia POLST Collaborative. In 2010 he retired from medical practice, where he was a Resurgens Orthopaedics’ orthopedic surgeon specializing in total joint replacement to become the Medical Director of the Ethics Program at Wellstar Health System in Atlanta, Georgia. Here’s what he told me:
The Georgia Hospital Association released a Memorandum in May 2014 based on their research, outlining several legal issues with the Georgia Department of Public Health’s POLST form. Four uncertainties with the POLST remain:
- Signatures: need to eliminate conflicts.
- Transferability: currently implied but not stated.
- Immunity: exists for “persons” acting in good faith, but immunity is not currently spelled out for “healthcare provider(s)/team” and “healthcare facility”.
- Healthcare advocate/authorized person: must be named in an Advance Directive or Power of Attorney.
As a result, currently metro area Atlanta hospitals will accept a Georgia POLST, but currently are not promoting it. Promotion of the Georgia POLST will resume when these issues are resolved.