Terri Schmidt, an emergency room doctor at Oregon Health and Science University, can鈥檛 forget the day an elderly man with congestive heart failure came into the hospital from a nursing home.
The man hadn鈥檛 filled in a medical directive form, so, by law, Schmidt had to provide all the medical care possible.
鈥淚 intubated the man. I did very aggressive things. It didn鈥檛 feel right at the time,鈥� says Schmidt. 鈥淭here was just this sense in my mind that this is a 92-year-old very elderly person with bad heart failure. And about 15 minutes later, when I was able to get ahold of the family. 聽They said, 鈥榊ou did what? 聽We talked about this! He didn鈥檛 want it. We had a big conversation in his room about a week ago.鈥欌��
Oregon has been in the forefront of trying to make sure a person has as much control over the end of his or her life as possible. The state pioneered a form known as a , for Physician Orders for Life-Sustaining Treatment, that has been adopted by 14 states and is being considered in 20 more. The form offers many more detailed options than a simple 鈥渄o not resuscitate鈥� directive.聽聽聽
That鈥檚 good for Helen Hobbs, who is 93 and lives in an assisted living facility in Lake Oswego. Age has bent Hobbs low and she uses a walker, but she is very clear-headed on this topic.
鈥淵ou know, death is part of your life. You know you鈥檙e going to get there someday so let鈥檚 make it as pleasant as possible,鈥� Hobbs said. 鈥淚 mean, would you like to stay in an unconscious condition for years while people kept you alive with feeding and hydration tubes? No.鈥�
Hobbs outlined her end-of-life medical decisions a couple of years ago, after a serious surgery. She used Oregon鈥檚 form. It is signed by her doctor, so it鈥檚 legally enforceable.
Reading it, Hobbs says she likes the fact that it offers a lot of different options.
鈥淵eah, I did want antibiotics in case of infection. I don鈥檛 want CPR if I鈥檓 in cardiac arrest. I don鈥檛 want to be tied down with tubes,鈥� Hobbs says. 鈥淵ou know there鈥檚 no point in prolonging it. I mean, death can be natural and it鈥檚 not that bad.鈥�
Administrators at her senior residence advised Hobbs to keep her POLST form in a plastic tube in her freezer, so EMTs will know where to find it. Other nursing homes tell residents to keep their forms under the sink or on the fridge. It鈥檚 not exactly a perfect system.
Consider the case of Wanda Pucket from Eastern Oregon. Despite being 85 and close to death, she was airlifted to the hospital; given extensive surgery; and kept alive in the intensive care unit for days. Pucket had a form outlining her wishes not to be resuscitated, but nobody knew where it was. Her family couldn鈥檛 be reached before the extraordinary measures were taken.
Pucket鈥檚 daughter Kaye Hanni estimates the whole thing cost taxpayers close to $100,000.
鈥淪he would be so upset if she knew that kind of money was spent on her,鈥� Hanni says. 鈥淵es, we want to be humane and yes, we want people to treat us with respect. But is respect that kind of aggressive care?鈥�
To avoid situations like Pucket鈥檚, the Oregon legislature set up a database several years ago to deal with the problem of inaccessible POLST forms.
Now EMTs and doctors can access the state database to see if someone wants to be resuscitated.
That database is beginning to generate some interesting facts about the medical interventions people want as they die, according to of the Oregon Center for Ethics in Health Care.
鈥淲e have really learned that this is not a black and white process,鈥� Tolle says. 鈥淟ess than 10 percent of people wanted to refuse all treatment. A majority want some things and not other things.鈥�
Tolle avoids the topic of whether these detailed end-of-life instructions save money; she is wary of starting another 鈥渄eath panels鈥� debate. But the database has allowed the state to quantify the policy by some measures.
鈥淲hat we found was that if people marked 鈥榗omfort measures only鈥� and 鈥榙o not resuscitate鈥� and did not want to go back to the hospital鈥here was a 67 percent reduction in life sustaining treatments, primarily hospitalization and emergency room visits,鈥� says Tolle.
Still, you don鈥檛 have to look far to find people who don鈥檛 like the forms. is a professor of moral theology at the Saint John Vianney Seminary in Denver.
鈥淚鈥檝e heard often that elderly patients can feel pressured by the medical community or by their family, not to be a burden,鈥� says Brugger. 鈥淚 think those kinds of pressures are very hard to calculate. And we want to be very careful that we don鈥檛 put those kinds of pressures on the elderly.鈥�
Brugger says giving a family member, or friend, a durable power of attorney is a much better solution to this delicate issue.
But Helen Hobbs says she filled in her POLST form to make sure her son doesn鈥檛 have to make difficult decisions as her life ends. She was grateful her husband had made his decisions known before he died.
鈥淲hen somebody鈥檚 unconscious and not going to get better, it鈥檚 kind of silly to put them on a feeding tube,鈥� Hobbs says, recalling how she refused that option for her husband. She was at peace with the decision. 鈥淲e had talked about it together many times and neither one of us wanted that kind of treatment.鈥澛�
This article was produced by Kaiser Health News with support from .