POST and Advance Directives
ADVANCE DIRECTIVES and POST
What Are They and How Do They Relate to Each Other?
An Advance Directive (AD) is a document in which a person sets forth future health care decisions that he/she would want made should he/she become unable to speak for self due to an unforeseen injury or illness. SC recognizes two types of advance directives, the Health Care Power of Attorney and the Living Will (outlined in the Death with Dignity Act). SC also acknowledges The 5 Wishes, but this booklet is cumbersome when trying to identify someone’s wishes in a crisis. An advance directive is a legal document. Per the National POLST Paradigm, “The wishes of patients as expressed in an advance directive often prove ineffective in directing care because: (1) they do not address the specific here-and-now medical circumstances of the patient; (2) they often do not get recorded in the medical record; (3) they do not necessarily follow patients across care settings; and (4) they do not dictate a care plan through medical orders and clinical protocols.”
The Physician Orders for Scope of Treatment (POST) is a transportable medical order which is signed by a physician and the patient. Usually, a patient does not sign a medical order, but in this case, it serves an important purpose. The patient’s signature indicates that the patient has shared in the decision-making process and agrees with the orders on the form. This helps health care personnel have actual knowledge of the patient’s wishes as set forth in SC 44-66-60 (B). The POST is completed after an in-depth conversation is held with the patient to help identify that person’s values, beliefs and goals of care.
Whereas, an AD is meant to cover potential future events, the POST is a set of medical orders for a known serious illness or advanced frailty where it would not be a surprise if the person died within the next 12 months.
Advance directives and POST are both a part of advance care planning which looks to have a person’s wishes for treatment honored. Although being different in their intent, they complement each other. POST is not meant to replace ADs. All adults should complete an advance directive, specifically the Health Care Power of Attorney, to name a surrogate decision maker. The advance directive should be reviewed and updated periodically throughout the years. When a patient with a serious illness or advanced frailty meets the criteria of POST, then the medical order should be completed after the appropriate conversation. The POST should also be updated as needed.
One huge difference between the advance directive and POST is the fact that an AD does not guide EMS in the field. The POST does. An example of this is a patient who has chosen not to be resuscitated should they be found without a pulse or respirations. When responding to the call, EMS finds that they are still breathing and have a pulse. An advance directive does not help in this scenario as there are no actionable orders. Section B of the POST can guide EMS as to the level of treatment wished for by the patient (full, limited or comfort care) allowing the patient’s wishes to be honored.
The question arises that if a patient arrives for treatment with an AD and POST, which takes precedence over the other. There really is no relationship between the two to establish “precedence”. Again, POST is a medical order and is actionable by health care providers, while an AD is not. The default would be to follow the POST medical orders. If there is disagreement between the AD and POST, again POST is the default medical order. To help mitigate this incongruence between documents, all conversations about POST orders should always include a recommendation that the person review and update his/her AD to make it congruent with the POST orders. If the patient is awake and has capacity, he/she can revoke the POST at any time, verbally or in writing. Also, an appointed surrogate can revoke a POST if that is based on the patient’s known wishes (SC 44-66-30 (G) if the patient is unable to speak for self.