Saturday, June 15, 2013

POLST Authorizes Unilateral DNAR Orders

In both Maryland and Vermont, a clinician can write a POLST order indicating "no CPR" even without patient or surrogate consent.  Regulations in both states authorize the entry of a "do not attempt resuscitation" order on a POLST on the basis that CPR would be "futile" or "medically ineffective."  This "no consent" option is clearly printed right on the POLST form.

California law similarly provides that while "a health care provider shall treat an individual in accordance with a POLST form," that requirement "does not apply if the POLST form requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution."  But unlike Maryland and Vermont, the "no consent" option is not printed on the POLST form itself

Nevertheless, this has not prevented California providers from utilizing this option.  For example, Dominican Hospital in Santa Cruz, rewrote a patient's POLST contrary to his prior expressed wishes, apparently on the ground of medical ineffectiveness.  Of course, since the patient was unbefriended / unrepresented, there was little risk that such a decision would be challenged.  It is unclear that clinicians would rewrite a POLST on grounds of ineffectiveness in the face of surrogate opposition.   

Many states have long allowed clinicians to unilaterally refuse (surrogate-, agent-, or surrogate-requested) treatment that is "medically ineffective" or that is "contrary to generally accepted health care standards."  But since there is significant uncertainty about when those standards are satisfied, clinicians have generally declined to avail themselves of such safe harbors.  It is unclear, yet, whether analogous POLST safe harbors will be any more effective.

17 comments:

Judy Citko said...

Please note that in California, a POLST form must be signed by both (1) the patient or their decision maker, and (2) a physician. CA Probate Code Section 4780. If it does not have both signatures, it is not a legally valid POLST.

Thaddeus Mason Pope, J.D., Ph.D. said...

Thank you, Judy. That is a good distinction.

Maryland and Vermont permit the issuance of a POLST with a DNAR order on the basis of ineffectiveness - ex ante.

California does not do that. A California POLST always needs consent (patient/surrogate signature).

Instead, what California law does is excuse, on grounds of ineffectiveness, the clinician's obligation to comply with a POLST indicating CPR.

So, California has no ex ante unilateral DNAR. It just permits noncompliance with POLST at the moment a requested intervention becomes relevant.

Note though that the California excuse applies to ANY order on the POLST and not just CPR like MD and VT.

Also, it seems that an ex ante judgment could be made that an intervention would be ineffective. While an altogether new POLST could not be written, the physician could leave internal to the facility instructions for DNAR.

Anonymous said...

To get an oil change at my Maryland car dealership I have to sign a consent form, but for matters of life-and-death my doctor’s word is good enough (Maryland’s MOLST and DNR forms requires only that a doctor certify that there was a discussion). Casting no aspersions on doctors’ honesty or motivation, one would think that forms of such import would require a patient’s signature just to be on the safe side.

I have little doubt that requiring my signature would have prevented what happened to my father at a Maryland hospital (see holycrosshealth.com).

Anonymous said...

In Response to the writer, above. I agree with your comments but there is no way to reach you once one gets to holycrosshealth.com

You have my sympathy over what happened to your Father. I also had a horrible experience with a covert DNR put into my elderly husband's chart to shorten his life to hide a mistake, an error, that the hospital and treating physician knew would not be reimbursed by Medicare and Tricare for Life.

Because of CMS and big Private Insurance Reimbursement Protocols of the past ten years, physicians/hospitals take a calculated risk in treating the elderly and rationalize that the elderly are better off dead if there is any chance that they will become "charity" patients of the hospitals.

This, of course, is against the law but the law turns its back on this worst kind of elder abuse ---which is against the law and would be treated as a crime in many States ---but, of course, is never prosecuted.

Apparently, it is just easier and more profitable for the powers that be who run the nation's hospitals to kill the very elderly to make sure they will not end up dying in their ICUs in violation of public policy goal of the 1991 Patient Self Determination Act that envisions that the elderly will die in their own residences or nursing home residences at much less expense to Medicare and it's private partners, Big Insurance. .

It is not an accident that there are NO PROCEDURAL protections against NO CPR and DNR code status being unilaterally and overtly and covertly placed in the hospital charts of the elderly on Medicare and Medicaid.

Our country has lost its soul!

crystal wilson said...


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crystal wilson said...


I was crushed when my lover of three years left to be with another woman. I cried and sobbed every day, until it got so bad that I reached out to the Internet for help.And i saw a testimony of a spell caster who help a girl called michelle and i said let me give it a try so i contact him for help and he cast a love spell for me which i use in getting my love back and now i am a happy woman.For what you have done for me,i will not stop to share your goodness to people out there for the good work you are doing.I hope God blesses you as much as you have help me to get my Love back,visit him on oriomonspiritualtemple@yahoo.com is the only answer to your problemS
EMILIANO BABARAH_USA

crystal wilson said...


I was crushed when my lover of three years left to be with another woman. I cried and sobbed every day, until it got so bad that I reached out to the Internet for help.And i saw a testimony of a spell caster who help a girl called michelle and i said let me give it a try so i contact him for help and he cast a love spell for me which i use in getting my love back and now i am a happy woman.For what you have done for me,i will not stop to share your goodness to people out there for the good work you are doing.I hope God blesses you as much as you have help me to get my Love back,visit him on oriomonspiritualtemple@yahoo.com is the only answer to your problemS
EMILIANO BABARAH_USA

Anonymous said...

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dr okorospell said...

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Dora Lawson said...

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crystal wilson said...

GREAT FATHER



HOW DR.ORIOMON HELP ME BRING BACK MY EX HUSBAND BACK TO ME


hello to the every one on this forum ; am here to share my experience with dr oriomon about what he just did for me last week , for helping to reunited with my ex lover Mavis who broke up with me after 2 years of relationship because of his families did not like our relationship . but after Dr oriomon of oriomonspiritualtemple@gmail.com has done his wonderful work for me i was so shock when i saw Mavis calls on phone asking me to come back to him that him is ready to stay with me and beg his families to love our relationship and he actually did so and with a support from DR ORIOMON his parents that never wanted to see both of us promise to sponsor our wedding by December as we are planing now . so with this great work done for me by DR oriomon i promise not to stop telling others about his good work in my life , so if any one also need his help here i will advice you contact him to via (oriomonspiritualtemple@gmail.com) bye

CLARA BENJAMIN _ CANADA



DR.ORIOMON THE GREAT MAN OF ALL SPELL CASTER

crystal wilson said...

GREAT FATHER



HOW DR.ORIOMON HELP ME BRING BACK MY EX HUSBAND BACK TO ME


hello to the every one on this forum ; am here to share my experience with dr oriomon about what he just did for me last week , for helping to reunited with my ex lover Mavis who broke up with me after 2 years of relationship because of his families did not like our relationship . but after Dr oriomon of oriomonspiritualtemple@gmail.com has done his wonderful work for me i was so shock when i saw Mavis calls on phone asking me to come back to him that him is ready to stay with me and beg his families to love our relationship and he actually did so and with a support from DR ORIOMON his parents that never wanted to see both of us promise to sponsor our wedding by December as we are planing now . so with this great work done for me by DR oriomon i promise not to stop telling others about his good work in my life , so if any one also need his help here i will advice you contact him to via (oriomonspiritualtemple@gmail.com) bye

CLARA BENJAMIN _ CANADA



DR.ORIOMON THE GREAT MAN OF ALL SPELL CASTER

LEONARD WILSON said...

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LEONARD WILSON said...

At last my happiness has been restored by a Man named Dr ABULU ,, my name’s are miss KIRSTEN I want every one on this site or forum to join me thank this DR ABULU for what he just did for me and my kids. my story goes like this I was married to my husband for 5 years we were living happily together for this years and not until he traveled to Italy for a business trip where he met this prostitute who be witched he to hate me and the kids and love her only so when my husband came back from the trip he said he does not want to see me and my kids again so he drove us out of the house and he was now going to Italy for to see that other woman. so I and my kids were now so frustrated and I was just staying with my mum and I was not be treating good because my mama got married to another man when my after my daddy death so the man she got married to was not treating I and my kids well so I was so confuse and I was searching for a way to get my husband back to me and my kids so one day as I was browsing on my computer I saw a testimony about this MAN DR ABULU of abuluspiritualtemple@gmail.com shared on the internet by a lady and it impress me too so I also think of give it a try at first a was scared by when I think of what me and my kids are passing through so I contact him and he told me to stay calm for just two days that my husband shall be restored to me and to my best surprise I received a call from my husband on the second day asking after the kids and I called Dr Abulu and he said your problems are solved my child so this was how I get my family back after a long stress of brake up by an evil lady so with all this help from DR ABULU of abuluspiritualtemple@gmail.com I want you all on this forum to join me to say a huge thanks to DR ABULU and I will also advice for any one in such or similar problems or any kind of problems should also contact him for help.

Anonymous said...

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Mercy brown said...

I’m Mercy brown by name I have a few testimony to share with you all about myself, I was in a relationship with this guy and for 3years and we were about getting married when we both have misunderstanding with each other and he ask me for a divorce and we both agreed and after 4months I head that he was having an affair with one of my closest friend and I was very upset and worried so a friend of my advice me and told me if I still love my ex and if I really want to have him back so I told her yes, and she ask me to contact Dr. Madurai the spell caster and I did although I never believe on spell so he gave me something when he was casting the spell and ask me to say my wishes on it and after the casting of the spell a receive a phone call from my ex and was ask me at which I did and now we are back together again I’m so happy and I wish not to ever have this mistake again in my life. I will also advice anyone with this kind of issue to contact him for help he is really nice on phone and always there to answer you question giving you the good advice that you need. his email is maduraitemple@yahoo.com