Hoping paperwork can cure high end-of-life costs

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The high costs associated with end-of-life care in New Jersey may be alleviated by, of all things, paperwork.

In late February, the New Jersey Department of Health and the New Jersey Hospital Association rolled out a new form to catalog medical orders for those facing life-limiting illnesses, to be given to any provider who may be in contact with the patient. The green POLST — or physician’s orders for life-sustaining treatment — form has been introduced in various places around the country as a way for physicians to work with patients to begin the conversation about goals for care and initiate corresponding actions.

“This is about honoring patient choice,” said Department of Health Commissioner Mary O’Dowd. “We hope that some of the other financial costs, the unnecessary costs, with care will be alleviated when individual choice is honored.”

By laying out choices on medical interventions, life support, and resuscitation, patients can use the POLST form to determine the course of action for health care providers in any setting, ensuring no unwanted treatment is administered.

At nine nursing homes and rehabilitation centers affiliated with the Princeton HealthCare System, a pilot POLST form has been swapped in for the traditional do-not-resuscitate form for the past year and a half, under the guidance of Dr. David Barile, a palliative care physician with the system and executive director of New Jersey Goals of Care.

“We’ve seen a very good impact on decision-making and smoothing transitions of care across health care settings,” Barile said. “There have been some studies published within states that have POLST programs that have demonstrated a cost savings, and it’s likely that we’ll see that impact here in New Jersey.”

O’Dowd also said the form can replace other end-of-life directive forms, and can serve as a script for providers to follow when starting the discussion. Dr. Gregory Rokosz, senior vice president of medical and academic affairs at St. Barnabas Medical Center, said the form is unique for New Jersey, as it is more comprehensive than other forms used in acute care.

For instance, the so-called do-not-resuscitate form “only addresses what happens when a patient undergoes cardiopulmonary arrest,” Rokosz said. “The POLST form, although it addresses that as well, addresses the goals of care and other treatments a patient and family might want leading up to that terminal event.”

Dr. Jeanne Kerwin, who directed Atlantic Health’s emergency services before becoming coordinator for ethics of palliative care at the system’s Overlook Medical Center, said calling 911 can be like getting on a high-speed train with no conductor. Without a POLST order, emergency medical technicians operate based on protocols, which will usually lead to intubation and hospitalization.

Kerwin said that, when Oregon first implemented the POLST form, EMTs said it changed the course of treatment for 45 percent of patients who had a form.

Elizabeth Ryan, president and CEO of the New Jersey Hospital Association, which led the POLST creation steering committee, said that while she can’t quantify the exact impact of the form in other states, “we definitely have room to improve, and at the end of life, more care is not always better.”