Physician Orders for Life-Sustaining Treatment (POLST) in F lorida

1. Physician Orders for Life-Sustaining Treatment (POLST) in Florida Marshall Kapp, J.D., M.P.H. Center for Innovative Collaboration in Medicine and Law Florida State University marshall.kapp@med.fsu.edu

2. Background • Florida Advance Directive Law • Instruction directives (Living Wills), F.S. § 765.302 • Surrogate (agent) appointment, F.S. § 765.202; Durable power of attorney, F.S. chapter 709, is functional equivalent. May withhold or withdraw life-prolonging treatment if: • No reasonable probability of patient recovering capacity • End-stage condition, terminal, or PVS

3. Substituted judgment (How much evidence?) • Best Interests standard

4. Do Not Resuscitate (DNR) Orders • Florida Statutes § 401.45(3) • Implemented by Fla. Admin. Code r. 64B8-9.016 • Department of Health “Yellow Form,” DH Form 1896, http://www.doh.state.fl.us/demo/trauma/PDFs/DNROFormMultiLingual2004.pdf

5. Default statute, F.S. § 765-401, authorizes a “proxy.” • Spouse • Adult child(ren) • Parent • Adult sibling(s) • Close relative • Close friend • Clinical social worker selected by ethics committee

6. Guardianship • Ad hoc, default, bumbling through

7. Problems with the Status Quo • Patients without directives +/or agents • Interpretation and application disagreements • Document portability questions • Inadequate enforcement mechanisms • Surrogates or Proxies disagree, won’t decide, make decisions based on conflicts of interest

8. POLST as the Next Generation of Advance Planning • Nomenclature varies • Definition • Physician order, notan advance directive • National movement, www.polst.org

9. The POLST PARADIGM • Applicability • Not for everyone • People with advanced illness or frailty, whom the physician would not be surprised to see die within a year • Does not get implemented if patient is still decisionally capable

10. Advantages over advance directives • Combines the patient’s expertise on values and the physician’s expertise of medical means to achieve those values. Structure for discussion (not just a form). • Follows the person across care settings • More likely to be honored • Allows for more precision, less need for interpretation

11. POLST ≠ Physician-assisted death (PAD)/Physisian-assisted suicide (PAS) • POLST is not about hastening death, but rather getting patients the kind of care they want. Patient-centered.

12. Florida POLST Status and Strategy • FSU Center as coordinator, http://med.fsu.edu/medlaw/POLST • Legal alternatives • Legislation • Regulation • Clinical consensus

13. Clinical consensus • Fla. Stat. § 765.106 Preservation of existing rights— The provisions of this chapter are cumulative to the existing law regarding an individual’s right to consent, or refuse to consent, to medical treatment and do not impair any existing rights or responsibilities which a health care provider, a patient, including a minor, competent or incompetent person, or a patient’s family may have under the common law, Federal Constitution, State Constitution, or statutes of this state.

14. Practical problems • DOH and Board of Medicine will not act without explicit legislative command • Physicians and EMS will not act without explicit immunity provisions • Conservative legal advice

15. 2015—POLST authorization and immunity in amendment to S.B. 1052 (Right to Try), then in substitute S.B. 1052, failed.

16. Ramifications for Current Law Practice • Representing Consumers— • Inform applicable clients and families of the POLST planning option, including its legal status. • Update and harmonize all advance planning documents. • Assure family understanding.

17. Representing Providers (in absence of explicit legislation)— • Facilitate POLST consideration or • Inhibit POLST consideration? • Identifying specific (versus free-floating) risks • Putting risks into reasonable perspective • What would it take to get attorneys over their apprehensions?

18. Policy/Statutory POLST Drafting Issues for 2016 • Should the form content be specified in statute? Must the approved form be used? • Which specific medical interventions should be listed as options? • Require statement of reasons (e.g., diagnosis) for the POLST for this patient? Restrict permissible reasons (e.g., require “terminal” illness)?

19. Who (besides physicians) may write a POLST? • Who (besides physicians) may discuss a POLST with the patient? • Must patient or surrogate consent be documented on the form by signature?

20. Extent of surrogates’ authority to consent to POLST on behalf of a patient lacking decisional capacity? • Immunity for providers for following a POLST? • Penalties for provider non-compliance? • Originals vs. Copies/Faxes? • Conflicts between POLST and advance directives?

21. Registry Questions • Who has access? • Confidentiality and security of data? HIPAA compliance? • Quality control, timeliness, updating of data? Liability for inaccurate data entry?

22. Policy Questions for Healthcare Institutions • How does POLST fit with institutional by-laws and protocols? • Recognition of POLST signed by physician without privileges in that institution? • Recognition of POLST signed by non-physician?

23. Conclusion • Legislation would only be the beginning: • Regulation/form development • Education of health care providers, public, and attorneys