The Physician Orders for Life-Sustaining Treatment (POLST) form, in use in the north west state of Oregon, has been hailed as an effective way to help patients avoid unwanted treatments.

It was developed following concern that patients' wishes were not being effectively communicated to doctors.

The medical establishment has often ignored wishes stipulated in advanced directives, documents drawn up about future health care prior to illness, usually on legal advice.

The POLST form was developed by a statewide task force and is distributed by the Center for Ethics in Health Care at Oregon Health Sciences University.

It is designed so terminally ill people can say what care they want to receive while they are suffering rather than before they get sick.

The patient's doctor must sign the form after discussion with the patient and their family.

Specific instructions

The POLST form contains specific instructions on:

• Whether the patient wishes to be resuscitated.

• What degree of medical interventions should be used.

• Antibiotic use.

• Feeding procedures.

The form is designed to follow the patient across different treatment settings, for example, from a hospice to an emergency room.

An assessment of the forms, published in the Journal of the American Geriatrics Society, showed that among 180 patients who had indicated "Do Not Resuscitate" on their POLST form, not a single patient received cardiopulmonary resuscitation, intensive care unit admission or ventilator support. And only 2% were hospitalised to extend life.

Of the 38 subjects who died during the year of the study, 63% had specified they wanted drugs and only two died in an acute care hospital.

Tragic stories

Dr Susan Tolle, director of the Center for Ethics in Health Care, said: "We all have heard tragic stories about patients whose wishes weren't respected, patients who had requested palliative care in a nursing home but after they break their hip end up in a hospital intensive care unit on a ventilator."

"What this study shows is that the POLST form focuses efforts on the patient's comfort, creating a positive plan that serves the patient.

"Nursing home patients in the study received remarkably high levels of comfort care and low rates of aggressive life-extending treatment."

Five year gestation

Dr Tolle was part of a multidisciplinary task force that drafted, refined and tested the POLST form over a five-year period.

"The form was designed to give specific guidance to physicians," she said.

"But it also helps patients, families and health care providers discuss these critical end-of-life issues."

Discussion appeared to take place not only when the POLST form was completed, but throughout a patient's stay in a nursing home - and it appears to benefit the family as well as the patient.

For example, in 67% of cases where a study patient died, an additional family conference was held with nursing home personnel shortly before death.

Easy to understand

Dr Tolle said the POLST form was effective because it was standardised, clear and, because it was shocking pink, hard to ignore.

However, she warned that the same system would only work elsewhere if, like Oregon, adequate resources were made available for care of the dying.

She said: "Anyone who looks at the POLST as just a way to limit care - and cut costs - is playing an unethical game. You can't let people choose to limit care unless they have other real choices too."