Seriously ill individuals in Michigan will soon have another tool to give them additional control over the course of their care outside of a hospital. A new law in Michigan aligns it with other states authorizing “Physician Orders for Scope of Treatment” (“POST”) forms to allow a seriously ill individual and his/her physician to agree on specific orders for use or withholding of various kinds of advanced life sustaining treatment.
It will be a while before we have a usable POST form in Michigan. The new law requires that a formal governmental committee be appointed to make recommendations about many aspects of the POST form before the Michigan Department of Health and Human Services (“MDHHS”) drafts the form. Under the new law, the committee work likely will not be completed until late 2018. After that, MDHHS will have an unlimited amount of time to act upon the committee’s recommendations. MDHHS is also required to promulgate administrative rules to address the details of preparing and using a POST form. Accordingly, much is still unknown about what the POST form will look like and how it will work.
We do know some basic information about the POST form, though, because of the terms of the new law itself that neither the committee nor MDHHS will be able to change.
- Emergency medical responders and health professionals in settings other than hospitals will be able to implement those orders without any further contact with the physician.
- The POST form will not function as physician orders in a hospital. But doctors in a hospital will be able to use the form as a “communication tool” as the new law says. Presumably this means that the hospital doctors will be able to see what the patient’s attending physician and the patient agreed upon, and then incorporate those decisions into their own plan of care if they choose to.
- A patient, guardian or patient advocate can sign a POST form. The new law gives guardians and patient advocates guidelines on how to decide whether to sign a POST form and what physician orders to agree to.
- POST forms must be reviewed periodically and when certain key changes happen.
- The new law permits an Advocate, guardian, or attending physician - in addition to the patient personally - to revoke the POST form in certain situations.
POST forms are different from Do Not Resuscitate Orders and Patient Advocate Designations (a/k/a Durable Power of Attorney for Health Care)–both of which have been available to Michigan residents for years–in the following ways:
- POST forms are very similar to Do Not Resuscitate Orders, but apply to many more kinds of treatment than just administration of CPR. Until MDHHS distributes the official POST form, we won’t know the type of treatment modalities it will address. It likely will cover ventilators, blood transfusions, kidney dialysis, intravenous solutions, and tube feedings. Many seriously ill individuals have strong feelings about these kinds of treatments, and decisions about them are often difficult for patients, families, and health care providers.
- POST forms are quite different from Patient Advocate Designations. In a Patient Advocate Designation, a patient names an individual (the Advocate) to make treatment decisions for the patient if the patient is unable to do so. The patient may also express care wishes to guide the Advocate. Conversely, a POST form is an executable physician order that tells health care professionals exactly what to do just as though the physician were present.
While we wait for the committee and MDHHS to do their work, there are a number of potential issues to be considered:
- How will POST forms, Patient Advocate Designations and Do Not Resuscitate Orders all work together? What if there are different instructions in these documents? The new law gives us some answers, but not all questions are resolved. Obviously best practice is for a patient to simultaneously update and harmonize all three documents on a regular basis, but this will not always happen.
- How binding are the POST orders? The law does not require that Emergency medical responders must follow the orders in the POST form in all situations. This provides needed flexibility to adapt the POST form to nuanced circumstances – but will it also have the unintended effect of disregarding a patient’s wishes?
- Will the POST form accommodate individualized orders that allow the patient and attending physician to narrowly hone application of the order to differing patient conditions? Or will the POST form be a one-size-fits-all list of check boxes? If the latter, how will physicians and patients address variations in patient need and wishes?