Dr. Thomas Rex Flygt

Text version of Dr. Thomas Rex Flygt keynote remarks

Several months ago, social workers at the care center asked for help to improve orders on life-sustaining treatments, which were increasingly "thicker" than the traditional "do not resuscitate" order, including (for example) "do not intubate", "do not hospitalize" and/or "do not tube feed." Our sensitivity to issues in end-of-life care had outgrown the system we used to use for communicating and respecting choices.

The staff at St. Clare Meadows was immediately interested in my description of the POLST paradigm:  POLST is a fifteen- to twenty-year old, Oregon-born system that offers a means for maintaining a "thicker" order than just "DNR."  It's available to the living (not just the dying).  It's portable (good until explicitly cancelled).  It's private (bracelet-free).

In principle, it should have been easy to "just do it":  POLST has been endorsed by the National Quality Forum as a "best practice" in end-of-life care across the continuum of care.  It is the single most widespread DNR-type order system in use today. 

But then there was the obstacle: The hospitals.  Hospitals tend to view all care as episodic--the idea of an order that would last from admission to admission was, frankly, foreign.  And inertia--does anything have more inertia than a hospital?  And pride--hospitals are used to telling nursing homes what to do.  So you need courage to tell hospitals you're going to change them.

Why change?  We all know that at the deepest level, healing can occur only when our patient's choices are honored.  Physicians can do fine disease management in the biomedical paradigm without ever eliciting their patients' preferences.  But at the end of life, respecting patients requires something more robust, something more profound.  There is no more consequential event in life than death.  At the end of life, we have to know what people want.  True healing--the creation of balance or harmony in the resolution of life's journey--requires talking to patients.  The team has to work in a biopsychosocialspiritual model.

As a postscript (because this may be the most important thing I say), please listen to a description of what we call "Viking Navigational Instinct" in my family based on my reflections on my Scandinavian heritage: When you think you're thoroughly lost, reflect for a moment about all those who've gone before us whose actions led us here.  And think not only about the specific instructions they left, but also the companionship their spirits still offer.  While you may not be able to visualize Mother Mary Odilia Berger in a Viking hat, trust me that she and others have left us a heritage of good instructions and a persisting sense of companionship--that's where courageous leadership comes from.

Go now and implement the POLST paradigm.  In doing that, you will create a record of health care that is not just epic in length and cost, but epic in the way it faithfully respects the character of its principal actors.