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Sunday, April 18, 2010

New tools allowing people die at home, not in the hospital

Doug State entered hospice care two years ago knowing exactly how he wanted to die: at home in Cambridge, Minn., with his wife, Carol, and his dog, Teddy.

He got his wish a year ago at age 83, when his failing heart finally stopped just as he was sitting down to breakfast at his kitchen table. What Carol State remembers most clearly about that moment is that she was able to hold her husband and tell him she loved him as he left her life forever.

It almost didn’t happen that way. But State was one of the first people in Minnesota to obtain a new kind of medical document that told his family and doctors exactly what kind of care he wanted at the end of his life.

Now, that same directive is slowly being adopted at hospitals, nursing homes and hospices as part of a quiet groundswell within the medical community to give terminally ill patients more control over how and where they die.

The document has an awkward name – Provider Orders for Life-Sustaining Treatment, or POLST – but it seems to work. Where it is standard practice, most notably Oregon and La Crosse, Wis., far fewer people die in intensive-care units hooked up to machines they didn’t want.

More importantly, experts say, the document and the careful decisionmaking that precedes it lift an emotional burden from patients’ families.

“If he had been in a hospital, we would have had to make the decision to pull everything,” said Carol State, 71. “He saved us from having to make it.”

Such end-of-life medical planning is assuming more importance in the debate over a health-care overhaul, and has even turned into a red-hot political ignition point. Proponents argue that billions of dollars are wasted on aggressive, expensive medical treatments for people in their last weeks of life. Opponents have derided such end-of-life planning services as “death panels.”

In recent years, Americans have tried an array of tools to direct care at the end of life -- living wills, advanced care directives and do-not-resuscitate (DNR) orders. Most of the time, experts say, they don’t work. For example, polls show that 90 percent of people say they want to die at home, but only 20 percent do.

Advanced directives and living wills are long, complex legal documents, experts say. Often they grow outdated or lie buried in a drawer at home, little use to frantic relatives or doctors, nurses and paramedics who have to make instantaneous decisions in an emergency.

To replace them, Minnesota’s largest health-care organizations have a statewide plan to do more advanced care planning and to make POLSTs the standard of care for patients in hospice or long-term care.

The documents will be placed with other medical records – a uniform bright yellow, so relatives or paramedics can find them.

This year Allina Health System plans to use specially trained staff to talk to at least 4,000 patients about end-of-life planning, including POLSTs for 1,500 patients in hospice and long-term care.

Some health care experts remain skeptical that POLSTs solve the underlying problem.

“We basically have an ongoing non-discussion on the topic of end-of-life planning” in this country, said Dr. Steven Miles, a bioethicist at the University of Minnesota. “Until families talk about it, it doesn’t make any difference how you rearrange the bureaucracy.”

Nonetheless, over the last two decades POLSTs have made a difference in La Crosse. Dr. Bud Hammes, who has led the program there for two decades, said the key was giving the responsibility to trained nurses and facilitators, not doctors, and making it a regular part of health care.

Today, he said, at death 96 percent of the patients at La Crosse’s Gundersen Lutheran hospital have an advanced care directive, a POLST or both. Only 30 percent die in the hospital, compared with 50 percent nationally.

Experts say it could take a long time before POLSTs become routine elsewhere. But they already have at least one convert.

Doug State lived his last days at home with his wife and the pets he loved, and died at his kitchen table without tubes or machines, just as he planned. “I want to die just like he did,” said Carol State. “Wouldn’t that be what we all want?”