WSMA Wellness Report

Published 4/16/2014 

Know Your Choices: National Healthcare Decisions Day, April 16

Today is National Health Care Decisions Day! The WSMA, via its Know Your Choices – Ask Your Doctor campaign as well as Honoring Choices Pacific Northwest, is joining other national, state and community organizations to help bring attention end-of-life care planning today through traditional and social media.

The ultimate goal for NHDD and WSMA’s end-of-life initiatives is to encourage patients to express their wishes regarding health care at the end of life, and for providers and facilities to respect those wishes, whatever they may be (the fact remains that only a small minority of Americans has engaged in these difficult conversations).

This issue of WSMA Wellness Report contains a look at WSMA’s advance planning resources for patients. The individual articles can be shared via social media, email, etc. And check out WSMA Doc Talk on Twitter and on Facebook for additional information and resources.

Be sure to take a look at the new Honoring Choices Pacific Northwest website, an initiative started by the WSMA and the state hospital association to provide patients, families and health professionals with the guidance they need for these difficult, but rewarding, discussions.

Also, WSMA member and Providence Chief Medical Officer Dr. Joanne Roberts was recently interviewed by KUOW Public Radio's Ruby de Luna about end-of-life planning & having the conversation, and her work with Honoring Choices Pacific Northwest. You can hear that discussion at the KUOW website.

Visit the NHDD website to find out what’s happening this April 16, and to learn more about the initiative.

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Published 4/16/2015

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Published 4/15/2014 

About Know Your Choices – Ask Your Doctor

Know Your Choices - Ask Your Doctor is a statewide campaign, sponsored by the WSMA, promoting various patient-centered health initiatives to enhance the relationship between patient and physician. With health care changing so dramatically and so quickly, it’s more important than ever for patients to have meaningful conversations about the best treatment options, expected outcomes and quality-of-life choices.

Know Your Choices - Ask Your Doctor focuses on three initiatives: Choosing Wisely®, End-of-Life Resources and ER is for Emergencies. Find out more about our campaign, and the variety of patient resources we have available, at, or via the links to the left.

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Published 4/15/2014

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Published 4/15/2014 

What is advance care planning? Hint: It’s important for everyone—even you!

Advance care planning is not just for older individuals—after all, a medical crisis can strike at any age, leaving someone too ill to make decisions about their health care.

What is advance care planning?

Advance care planning involves learning about the types of decisions that might need to be made, considering those decisions ahead of time, and then letting others know about your preferences, often by putting them into an advance directive. An advance directive is a legal document that goes into effect only if you are incapacitated and unable to speak for yourself. This could be the result of disease or severe injury—no matter how old you are. It helps others know what type of medical care you want. It also allows you to express your values and desires related to end-of-life care. You might think of an advance directive as a living document—one that you can adjust as your situation changes because of new information or a change in your health. (Source: U.S. Department of Health and Human Services National Institute on Aging)

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Published 4/15/2014

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Published 4/15/2014 

A town where 97% of residents have an advance care plan—and how they did it

What's the goal of events such as National Healthcare Decisions Day? That every community will be like La Crosse, WI, where roughly 97 percent (!) of residents have an advance care plan. Read how they did it in this NPR report

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Published 4/15/2014

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Published 4/15/2014 

Advance directives—your questions answered

In Washington state, you have the right to make your own health care decisions. Under the principle of “informed consent,” your medical care must be explained so you understand it and can make informed decisions. Treatment without consent, however, is allowed and will generally be provided in an emergency unless you indicate otherwise.

It is important to let your physician and loved ones know your wishes for treatment should you ever be near death and unable to express them. Most health facilities assume you want all available medical treatment, including life-sustaining care, unless you direct otherwise. Advance directives can help direct these decisions.

What are advance directives?
The term 'advance directive' refers to your oral and written instructions about your future medical care in the event you are unable to express your medical wishes. There are two types of advance directives: a health care directive (also known as a living will) and a durable power of attorney for health care.

Who can make decisions for me if I’m unable?
If you lose the ability to communicate and make decisions, Washington state law enables the following people, in order of priority, to make health care decisions for you, including withdrawing or withholding care:

  1. A guardian with health care decision-making authority, if one has been appointed.
  2. The person named in the durable power of attorney with health care decision-making authority.
  3. Your spouse.
  4. Your adult children.
  5. Your parents.
  6. Your adult brothers and sisters.

When there is more than one person, such as children, parents, or brothers and sisters, all must agree on the health care decision.

Making your wishes known in an advance directive will provide your doctor and your agent the clear guidance necessary to respect your wishes. The medical decisions made by your health care agent (as named in your durable power of attorney for health care) are as meaningful and valid as your own. The wishes of other family members should not override your own clearly expressed choices or those made by your agent on your behalf.

Health care directive (living will)
If you had a terminal condition, would you want your dying artificially prolonged? The health care directive is a legal document allowing you to answer this question in writing. This directive is used only if you have a terminal condition as certified by your physician, where life-sustaining treatment would only artificially prolong the process of dying; or you are certified by two physicians to be in an irreversible coma or other permanent unconscious condition and there is no reasonable hope of recovery. In either situation, the directive allows treatment to be withheld or withdrawn so that you may die naturally.

You may also direct whether you would want artificially provided nutrition (food) and hydration (water) stopped under these circumstances. Also in the directive, you can give further instructions regarding your care. The health care directive must be signed by you and two witnesses who are not related to you and will not inherit anything from you. You can change or revoke this directive at any time.

The health care directive allows people who clearly do not want their lives artificially prolonged under the above conditions to make their wishes known.

Durable power of attorney for health care
Who would you want making your health care decisions if you were unable? The durable power of attorney for health care is a legal document allowing you to name a person as your health care agent—someone who is authorized to consent to, stop or refuse most medical treatment for you if a physician determines you cannot make these decisions yourself. The person you choose should be a trusted family member or friend with whom you have discussed your values and medical treatment choices.

Do I need an advance directive?
Advance directives are the best possible assurance that decisions regarding your future medical care will reflect your own wishes, in the event that you are unable to voice these wishes. For this reason, every person aged 18 or over should prepare a directive

Do I need both a living will and a durable power of attorney for health care?
Yes. Having both a living will and a durable power of attorney for health care will provide the best protection for your treatment wishes.

A durable power of attorney will allow for some flexibility regarding treatment decisions, since the agent that you choose to represent your wishes will be able to respond to unexpected changes in your condition and base decisions not just on your written wishes, but also on their familiarity with you and your feelings regarding your care.

A living will is necessary to provide instruction in case your agent is unable to serve, to provide evidence that the agent is acting in good faith in case the agent's decisions are challenged, or to serve as the primary record of your wishes in case you are unable to appoint a health care agent.

Are advance directives legal?
Yes. There are federal and state laws that govern the use of advance directives. All 50 states and the District of Columbia have laws recognizing the use of advance directives. If you travel, you may want to take copies of your documents with you, as other states may honor these forms.

Will advance directives be recognized in emergencies?
No. During most emergencies, there is not enough time for emergency service personnel to consult the patient's advance directive. Once the patient is under the direct care of a physician, there will be time for the advance directive to be evaluated and/or the health care agent to be consulted.

For individuals with serious health conditions, there is a form in Washington state that can help represent your wishes in emergency medical situations called the Physician Orders for Life-Sustaining Treatment (POLST) form.

What to do with these forms
Signed copies of your completed directives should be included in your medical record, given to any person to whom you give your durable power of attorney—including any alternate people you may have named—and to your personal attorney. Originals should be in a safe but accessible place (not a safe deposit box) or given to someone you trust and who can obtain them in an emergency.

Discuss your wishes
It is essential that you have honest and open discussions with your appointed health care agent, doctor(s), clergy, and family and friends about your wishes concerning medical treatment. Discuss your wishes with them often, especially if your medical condition changes.

Can I change/revoke my directive?
You can always revoke one or both of your Washington state directives. If you choose to revoke your documents, make sure you notify your health care agent, alternate agents, your family and your doctor(s). If you wish to make changes to the directives, you should complete new documents.

Where can I get both advance directives?
WSMA’s advance directive patient brochure—“Who Will Decide If You Can’t?”—has been, and remains, the most popular of our patient resources. It contains both the health care directive and durable power of attorney for health care as tear-out forms, as well as explanatory text.

Find information on WSMA’s advance directives at the WSMA’s Know Your Choices – Ask Your Doctor campaign website at

For further information
You are encouraged to discuss the directives with your physician. Any legal questions you may have about the use and effect of these directives may be answered by an attorney.

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Published 4/15/2014

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Published 4/15/2014 

Talking with your doctor about advance directives: A discussion guide

The advance directive resource website MyDirectives offers an excellent guide to help you talk with your physician about advance directives.

Advance directives are simply a means by which you can communicate your preferences; their usefulness hinges upon your ability to express your wishes clearly, and for your family and physician to understand your wishes. Putting your wishes into words, getting more information and asking questions can help you get the kind of clarity, and the kind of care, you want.

The Advance Medical Directive Discussion Guide contains guidance on issues related to emergency medical treatment decisions, and provides you with specific questions to ask your physician regarding the following:

  • Artificial nutrition and hydration
  • Cardiopulmonary Resuscitation (CPR)
  • Hospice
  • Managing pain in serious illness and at life's end
  • Palliative care
  • Severe brain injuries
  • Autopsy & organ donation

Click here to review the full guide.

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Published 4/15/2014

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Published 4/15/2014 

Social media resources for National Healthcare Decisions Day

Join the National Healthcare Decisions Day (NHDD) celebrations on social media for a wealth of information on advance care planning. Follow along using the hashtag #NHDD.

Feel free to ask any questions you may have about advance care planning. Just use the hashtag #NHDD when posting your questions.

The following organizations are just some of the organizations participating on April 16:

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Published 4/15/2014

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Published 4/15/2014 

What is hospice care? What is palliative care?

Hospice care is intended to provide comfort to you and your family during a life-threatening illness, rather than provide treatments to cure the illness. Palliative care is similar to comfort care in hospice, but it is offered along with any medical treatments you might be receiving for a life-threatening illness, such as chemotherapy for cancer or dialysis for kidney failure. The main goal of both hospice and palliative care is to keep you comfortable. In addition, you can always choose to move from hospice to palliative care if you want to pursue treatments to cure your illness. (Source: U.S. Department of Health and Human Services National Institute on Aging)

Where can I find these services in Washington state?
Washington State Hospice & Palliative Care Organization (WSHPCO) is an organization of hospice and palliative care providers in Washington state dedicated to promoting and maintaining quality, compassionate care for those facing life-threatening illnesses. Patients may locate a hospice agency or palliative care program in the state via the WSHPCO website. A wealth of information is available on how hospice and palliative care providers care for those with a life-limiting illness.

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Published 4/15/2014

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Published 4/15/2014 

POLST: Further protection for the seriously ill—or those facing the end of life

The Physician Orders for Life-Sustaining Treatment (POLST) form is intended for any individual with a serious illness.

If you have a serious health condition, you need to make decisions about life-sustaining treatment. Your physician can use the POLST form to represent your wishes as clear and specific medical orders.

Your physician may use the POLST form to write orders that indicate what types of life-sustaining treatment you want or do not want at the end of life.

The POLST form asks for information about:

  • Your preferences for resuscitation
  • Medical conditions
  • The use of antibiotics
  • Artificially administered fluids and nutrition.

The POLST form is voluntary and is intended to:

  • Help you and your physician discuss and develop plans to reflect your wishes;
  • Assist physicians, nurses, health care facilities and emergency personnel in honoring your wishes for life-sustaining treatment;
  • Direct appropriate treatment by Emergency Medical Services personnel.

POLST – Your questions answered

What is the POLST form?
POLST is a medical order form that helps give seriously ill patients more control over their end-of-life care. Printed on conspicuous green paper, the POLST form can be used to summarize an individual’s previously expressed wishes for life-sustaining treatment and translate them into physician orders for medical treatment.

POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, and help ensure that patients’ wishes are honored.

What information is included on the POLST form?
The decisions documented on the POLST form include whether to:

  • Attempt cardiopulmonary resuscitation (CPR)
  • Administer antibiotics and IV fluids
  • Use a ventilator to help with breathing
  • Provide artificial nutrition by tube.

How does a POLST form work?
An attending physician fills out and signs a POLST form after talking with the individual (or the person's surrogate decision-maker) about preferences for various levels of treatment. (Nurse practitioners and certified physician-assistants are also allowed to sign the form in place of a physician.) The patient or surrogate decision-maker must sign the form as well.

The POLST form then moves with the patient from setting to setting, such as from emergency room to hospital to nursing home to home. The form reduces the need for repetitive end-of-life discussions and provides security for the individual and the physician that expressed wishes will be carried out. No other form streamlines the process in this way.

In a health care facility, the POLST form should be placed at the front of the clinical record. (When the patient and POLST form go elsewhere, the hospital should keep a duplicate of the form.) In the patient's home, the form should be in a prominent location. It will be recognized by emergency personnel as orders to be followed.

If I have a POLST form do I need an advanced directive too?
A POLST form does not replace a health care directive or durable power of attorney nor does an individual need either of those documents to benefit from a POLST form. If you have a signed POLST form, it is recommended that you also have an advanced directive, though it is not required.

If someone has a POLST form and an advance directive that conflict, which takes precedence?
If there is a conflict between the documents, the more recent document would be followed.

What if my loved one can no longer communicate her/his wishes for care?
A health care professional can complete the POLST form based on family members’ understanding of their loved one’s wishes. The appointed decisionmaker can then sign the POLST form on behalf of their loved one.

Can I change my POLST form?
Yes, you can change your POLST form at any time should your preferences change. It is a good idea to review the decisions on your POLST form when any of the following occur:

  • You are transferred from one setting to another, for example you go from your home to the hospital, or you are discharged from the hospital to a nursing home;
  • There is a change in your overall health, or you are diagnosed with an illness;
  • Your treatment preferences change for any reason.

What happens if I don’t have a POLST form?
Without a POLST form, emergency medical personnel, nurses and doctors would not know your treatment wishes. You will most likely receive all possible treatments, whether you want them or not. Talking about your treatment choices with your loved ones and doctor before a problem occurs can guide them and help ensure you get the care you want.

Are faxed copies and/or photocopies valid? Must green paper be used?
Faxed copies and photocopies are valid. Bright green paper is used to distinguish the form from other forms in the patient’s record; however, the form will be honored on any color paper.

What if I travel to another state – will my POLST form be valid?
The Washington POLST form is valid in Washington state. If you are traveling to another state, it is a good idea to take both your advance directive and your POLST form with you. Both documents, even if not legally binding, will help health care providers know your wishes.

How can I get a POLST form? How can I find out more about POLST?
Patients can request the form from their health care provider. It is important to discuss your goals of treatment with your health care provider so you can decide if POLST is right for you, and how to document your decisions appropriately on the form.

For more information about POLST and related resources, visit the WSMA’s Know Your Choices – Ask Your Doctor campaign website at

The WSMA has remained the primary source of information and coordination of Washington state’s POLST program.

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Published 4/15/2014

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Published 4/14/2014 

POLST forms: Tool makes hard end-of-life decisions a little easier

The following story was the cover story for the October 2004 issue of WSMA Reports, the medical association's monthly newsletter. It introduced the then-new Physician Orders for Life-Sustaining Treatment (POLST) form with a compelling personal story, and remains relevant today.

Reprinted in edited form from WSMA Reports October 2004 issue.

By Jean Colley, Editor, WSMA Reports

Allison Douthitt’s husband, Robert S. Douthitt, 79, has been a resident at Saint Joseph Care Center in Spokane for two years, following a series of disabling strokes the first of which occurred in 1996. Like many other couples, both Douthitts wrote advance directives before they had experienced serious illness.

In their earliest directive, said Mrs. Douthitt recently, they indicated that they “wanted everything done.” With more strokes and the passage of time, they came to believe that they wanted no “extraordinary measures” taken, and replaced the old directive with a new one.

As Mr. Douhitt continued to have strokes, “we began to think more seriously,” she recalled. “We began to understand the nature of things, what it means to prolong life by artificial means, and the course of life and dying. We hadn’t really given that any thought.”

When their family physician, Dr. Jeff Collins, brought a “Physician Orders for Life-Sustaining Treatment” (POLST) form to their attention, “it sort of scared me at first,” she said.

The form permits a physician to translate the patient’s wishes into concrete physician’s orders. The POLST form contains specific instructions on whether the patient wishes to be resuscitated; what degree of medical interventions should be used (comfort measures only, limited interventions, advanced interventions or full treatment/resuscitation); antibiotic use and feeding procedures.

Dr. Collins had discussed issues of death and dying with Mr. Douthitt before he became unable to participate in the discussions. Following serious talks with Dr. Collins, in July 2002 Mrs. Douthitt signed the POLST form, selecting comfort care and limited intervention. “I wasn’t sure at first what comfort care is,” she said. “To tell you the truth, my initial impression was that he would have all food and all liquid taken away. Now I’ve seen first hand, I’ve been very impressed with the comfort measures here.”

She credits Dr. Collins with being of immense help. He not only cared for her husband, he recognized that she needed counseling to help her through the experience. In late September Mr. Douthitt was eating less. “I think we have everything in place and I am content with that,” she said. “I just want to let things go in their normal way. I don’t want to push food into him.”

* * * * * *

POLST forms are nothing fancy, except they that are supposed to be printed on fluorescent green cardstock. Unlike a living will or advance care directive which can be written at any time, the POLST form is designed to be used with patients who may die within the next year, have chosen “do not resuscitate” or “no code,” and wish a natural death with limited medical intervention.

Physicians who use them say they are valuable in opening a dialogue with seriously ill patients and their families over their concerns, fears and wishes in end-of-life care before a crisis engulfs them and decisions become much harder to make.

Just like other physician orders, once signed by the physician, the POLST form will be honored by emergency medical transporters and responders and hospital and nursing home professionals. Advanced registered nurse practitioners and physician assistants can also sign the form. Nurses can help patients fill out the form before it is signed by one of the other health professionals.

The form is unique, in that it is meant to remain with the patient—much like a driver’s license or other essential identification. In most places POLST is not wallet-sized nor is it in the form of a bracelet, but those options may be available in the future. When the patient is at home, the form should be kept in a conspicuous spot. If the patient goes to the hospital or is admitted to a nursing home, the form goes along and is placed at the front of the patient’s chart. When the patient leaves a facility, the form goes with the patient. With a POLST form, patients and their families can avoid having to answer the same questions in each new setting; they also can avoid unwanted care from medics if they call 911.

* * * * *

The original POLST form was developed in Oregon in 1991 in response to concerns that terminally ill patients were receiving unwanted care. In Washington, the catalyst was a state nursing home mandate that said that legal surrogates—those with a durable power of attorney for health care—had no power to voice in deciding against CPR, unless the patient fit in one of four categories. The categories did not cover common afflictions like Alzheimer’s disease. Guardians and physicians fumed over the mandate.

Around 1998 at a meeting with Department of Social and Health Services officials, Jim Shaw, MD of Spokane, representing RENEW (Regional Ethics Network of Eastern Washington), offered the POLST form as a solution and began the grassroots effort to get them approved and in use. After RENEW completed a pilot project in collaboration with DSHS, the WSMA and the Department of Health, DSHS notified nursing homes they could use forms like POLST, as long as they wrote policies and procedures for how the forms would be handled. Both WSMA and the Washington State Hospital Association have helped introduce and promote the forms and have endorsed their use.

Dr. Shaw said the burden on families could be lessened by having discussions of the options ahead of time. “POLST can facilitate those discussions,” he said. “We hope that this ‘preventive’ upstream approach is helpful. But death and dying are difficult and do not always follow our plan. And families may not all be in full agreement with the patient’s wishes. We stress good documentation of informed consent. We have both the patient and /or the legal surrogate sign, along with the physician.”

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Published 4/15/2014

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