Redacted POLST 2013

This redacted POLST form from March 2013 shows a "do not resuscitate" order stating that "the basis for these orders is (the) patient's best interest" as "discussed with (a) court-appointed guardian". The order calls for no antibiotics and no feeding tube. Here, the nonstandard question about antibiotics has been circled.

Patient preferences about what kind of end-of-life care they prefer are answered through a legal document known as POLST, provider orders for life-sustaining treatment, which is a traveling medical order that provides information about what kinds of treatment a patient who is seriously ill, frail, or near the end of life wants in the case of a medical emergency.

But DPHHS modified the form used at Spratt, apparently for years, by adding a nonstandard question that allowed patients to opt out of receiving antibiotics.

The standard POLST form used in Montana includes only three questions.

The first asks patients to decide whether they want to be resuscitated if they are found without a pulse and are not breathing.

The second offers a choice of three different treatment options for patients who have a pulse and are breathing:

• Comfort measures only, calling for providers to “relieve pain and suffering through the use of medication” and to “transfer to hospital only if comfort needs cannot be met in current location”.

• Limited additional interventions, allowing hospitalization for pain relief and some medical treatment but not “intubation, advanced airway interventions or mechanical interventions”.

• Full treatment, allowing for “intubation, advanced airway interventions, mechanical ventilation and cardioversion” as well as intensive care and hospitalization.

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The third and final question lets patients decide if they want to be given a feeding tube.

But psychiatrist Dr. Christina Quijano, who worked at Spratt for a temporary stint last year, told The Montana Standard that Montana State Hospital staff and administrators added a fourth and nonstandard question about whether patients want to be administered antibiotics.

Initially, Jon Ebelt, a DPHHS spokesperson, did not answer a direct question about whether such a question was included during Quijano’s time at Spratt, between early October and early December 2018.

But when a redacted copy of a POLST form from 2013 was provided to the Standard by another source, Ebelt acknowledged DPHHS “previously included the antibiotics question” and “removed it this spring and reverted to the standard POLST form for consistency with all primary care settings.”

So, while DPHHS officials deny that the way POLST forms are filled out at Spratt is pushy, unethical, or lacking in transparency, Quijano disagrees.

“It was a top priority that we made sure patients had a POLST as soon as possible — within the first 24 hours to the first week of hospitalization — and that their POLST was up to date and that it was up to date using their modified form that included a denial of antibiotics,” Quijano said.

She said she was also pressured to ensure the first question was answered "do not resuscitate" and that the second provided for comfort care only.

Quijano says she believes the hospital's addition of the nonstandard antibiotics question and the push for doctors to deny antibiotics was part of "a pretty aggressive stance on their (hospital administrators') philosophy to not provide treatment that would prolong life."

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