Frail and seriously ill patients undergoing emergency care would have a mechanism to inform paramedics and other first-responders of their treatment wishes under a bill awaiting Gov. Linda Lingle's signature.

Emergency care providers currently are required to attempt resuscitation, even if the patient has an advanced healthcare directive or living will to the contrary. Exceptions are made for terminally ill patients who have obtained a "comfort care only/do not resuscitate" bracelet from the state Department of Health through their doctor.

The recently passed legislation, House Bill 1379, establishes procedures for obtaining and using "physician orders for life-sustaining treatment," or POLST, documents that clearly state the patient's treatment directives in emergencies and other treatment situations.

"So many times when people don't express their wishes or don't have a POLST, in the panic of the moment what often happens is the family says, 'Omigosh, do everything for Dad,' and Dad ends up in the intensive care unit on a ventilator, having not wanted that," said Kenneth Zeri, president of Hospice Hawaii and Kokua Mau, a coalition of individuals and groups involved in end-of-life care. "He dies there and his last days of life are spent in suffering, not only for the patient but for the family, and it doesn't have to be that way. Most people don't want to die in the intensive care unit."

Other supporters include the state Department of Health; the city's Emergency Services Department; the Healthcare Association of Hawaii; the governor's Policy Advisory Board for Elder Affairs; and Hawaii Family Forum, a Roman Catholic family advocacy group.

According to the National POLST Paradigm Initiative Task Force, about half of the states in the country and a number of counties have endorsed or are developing POLST programs.

Lingle spokesman Russell Pang said Wednesday that HB 1379 is under review by the governor's policy team. Lingle has until July 15 to take final action on the bill.

In the meantime, the Health Department and other groups are working together to develop a brightly colored POLST standard form that can be posted on the refrigerator or some other visible location so that when 911 assistance is summoned, family members can have the document ready to present to paramedics and other first-responders.

"This follows you into the emergency room and gives the physician a document to start the conversation with family members about what kind of care to provide based on the orders," Zeri said. "Whatever the patient's choice is, this is a way to document that choice."

NOT FOR HEALTHY

The POLST form must be prepared by the patient's physician and is not valid without the signatures of the patient's physician and the patient or the patient's surrogate.

Unlike advanced directives, POLSTs are not meant for otherwise healthy people who suffer sudden life-threatening events. "People with chronic, debilitating illnesses who are in and out of the emergency room or hospital several times a year may want to think about it," Zeri said.

POLSTs also are not meant to replace traditional advance directives, which are recommended for all adults.

Dr. Daniel Fischberg, who specializes in pain management and palliative care at The Queen's Medical Center, was among those offering testimony in favor of HB 1379 during the legislative session.

"While an advanced directive can be a useful tool to summarize a person's values, beliefs and preferences for possible changes in future health, a POLST document provides real-time instructions for first-responders, emergency room personnel and other healthcare providers," said Fischberg, who cares for hundreds of terminally ill patients each year.

Supporters also point out that the "comfort care only" bracelet system allows just two choices — resuscitate or don't resuscitate. POLST documents let patients elaborate on whether they want aggressive interventions, tube feeding, intravenous fluids, mechanical ventilation, cardiopulmonary resuscitation or electrical shocks. Fischberg said in his testimony that patients could even request certain treatments such as tube feedings to see if meaningful improvements in health might occur and include instructions to stop the treatments if improvements do not occur.

Dr. Elizabeth Char, director of the Honolulu Emergency Services Department, noted in her legislative testimony that the bracelet system is designed only for patients with terminal conditions, and that obtaining a bracelet is a cumbersome process.

POLST forms would be widely available at various offices and online, and can be signed after a discussion with a physician.

"Many members in our community mistakenly think that having a living will is enough to prevent an unwanted attempt at resuscitation by emergency responders," Char said. "POLST will help ensure that if the person prefers to die a natural death, comfort care can be given by EMS personnel and that person's wishes can be respected."