30 Nov Ask Alice December 2020

We answer your questions about Advance Care Planning

Dear Alice,
Hi! In last month’s column, you mentioned something called a COLST, and enticingly said you would address it in a later issue. I don’t mean to be demanding, but can you do that sooner as opposed to later? I have an AD, but have never heard of a COLST. What does it stand for and how does it differ from an Advance Directive? Should everyone have one?
Thanks, Demanding

Dear Demanding,
No problem – ‘tis the season to make your wishes known!

COLST is an acronym for “clinician order for life-sustaining treatment.” As suggested by the name, a COLST is a document prepared and signed by a clinician (a doctor, nurse practitioner, or physician’s assistant) together with the patient or patient’s agent. It contains specific treatment decisions based on a discussion of the patient’s current medical condition and the patient’s values and wishes, and it becomes a binding medical order for current treatment decisions.

Although there is a fair amount of overlap in the medical questions and issues addressed by ADs and COLSTs, there are significant differences in their preparation and effect. When you prepared your AD, you probably talked it over with others, and this may have included medical providers. Ultimately, though, you were the one who filled out and signed your AD, choosing your agent and expressing your values and desires as guidelines for your future medical treatment. As noted above, however, a COLST is prepared by a clinician and patient together, based on a joint understanding of the patient’s medical condition and the patient’s wishes, and then signed by both.

Also, since a COLST is a binding medical order signed by a clinician, it will have a different effect in an emergency situation. In particular, a direction in an AD not to resuscitate you generally will not prevent an EMT responding to a 911 call from resuscitating you, while a medical order in a COLST not to resuscitate generally will. This is why the COLST form is brightly colored, and will usually be posted in a prominent location like a refrigerator or front door.

Your last question – “Should everyone have [a COLST]?” – is an excellent one, and the answer is “no.” While all individuals should have an AD if they are over 18, individuals are only encouraged to consider a COLST if they have serious, advanced, or life-limiting medical conditions; if they are certain that they want to avoid life-sustaining treatments; or if it would not be unexpected if they were to die within the next year. (Note that there is a reference to a COLST at the bottom of page 3 of the VT short AD form, suggesting that if you do not want to have CPR and/or other life-sustaining treatments under any circumstances, you should talk to your doctor about whether completing a COLST would be appropriate.)

From this discussion of differences, it is apparent that the roles ADs and COLSTs play in guiding medical decision-making are also different. Since everyone over 18 is encouraged to have an AD, many if not most individuals signing one are relatively healthy. These individuals recognize they cannot get very specific in their choices, because they are planning for an uncertain and hopefully distant medical future – but they also recognize they can increase their odds of getting what they would want by choosing their agent and articulating the values and desires now that will guide the agent in deciding what they would probably want later. As time goes by, individuals learn more about themselves and their medical conditions, and can change their ADs, perhaps making them longer or more specific, to provide more and better guidance. But by the time patients (or their agents) complete a COLST with a clinician, they are generally addressing a current medical situation. With the information from the clinician, they can be better informed about what is likely to happen, and the possible treatments and outcomes; and as a result they can make fairly specific choices that, with the participation and validation of the clinician, can become binding medical orders.

I hope this helps. Have a very happy and safe holiday season.
Best wishes, Alice

P.S. – In other states, the document we call a COLST is often called a POLST, a “physician order for life-sustaining treatment,” or a MOLST, a “medical order for life-sustaining treatment.”

As always, please contact Don Freeman, Taking Steps Brattleboro Coordinator, 802-257-0775, ext. 101, or don.freeman@brattleborohospice.org, for information about Advance Care Planning.

Till next month, folks. Please send your questions to Alice via info@brattleborohospice.org.