Preparing Your Community for the Physician Orders for Life Sustaining Treatment (POLST) Program

1. Preparing Your Community for the Physician Orders for Life Sustaining Treatment (POLST) Program

2. Presenter • Taya Briley, RN, JD, Director, Legal Services and Health Policy, Association of Washington Public Hospital Districts

3. What is POLST? • “Portable” physician order form describing the patient’s code directions--including antibiotics, nutrition and hydration, CPR • Travels with patient from one care setting to another • Can translate an advance directive into physician’s orders • DOES NOT replace an advance directive • Does replace EMS-No CPR form

4. POLST in Oregon • Taskforce formed in 1991 • Goal: ensure patient’s end-of-life care wishes are honored when patient is not able to speak for him or herself • Surrogate decision makers may communicate treatment preferences so physician can complete form when patient is incapacitated

5. POLST in Oregon-Good Results • Of 180 nursing home residents requesting comfort measures only, transfer to hospital only if comfort measures fail and DNR, two percent were hospitalized to extend their lives but none resuscitated against their wishes. • Tolle S.W., Tilden, V.T., Nelson, C.A., Dunn, P.M. A prospective study of the efficacy of the Physician Order Form for Life-Sustaining Treatment. (1998). Journal of the American Geriatrics society, 46, 1097-1102.

6. POLST in Oregon-More Good Results • Of 58 older adults enrolled in an all-inclusive care program, the medical treatments administered matched POLST instructions for CPR, antibiotics, IV fluids and feeding tubes more consistently than previously reported for advance directive forms. • Lee, M.A., Brummel-Smith K., Meyer J., Drew, N., London, M.R., Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly. (2000). Journal of the American Geriatrics Society, 48, 1219-1225.

7. POLST in Washington State

8. Initiating POLST in Washington • Pilot testing begins in Spokane and Whitman Counties in August of 2000 • Pilot supported by Washington State Medical Association PACE program grant • Washington State Department of Health and Department of Social and Health Services support pilot BUT...a serious issue with surrogate decision making must be addressed

9. Philosophy of POLST • Individuals have the right to make their own health care decisions • These rights include: • Making decisions about life sustaining treatment • Having a mechanism for describing their desires for life sustaining treatment to health care providers • Health care providers who understand how to provide comfort care while honoring the individual’s desires for life sustaining treatment

10. POLST vs EMS Form • Both are physician orders and recognized by the WA DOH and EMS (911) • Both allow for a DNR choice if the patient/resident has no pulse or respirations • Only POLST includes orders for medical interventions when patient/resident has pulse and/or is breathing

11. POLSTWho Should Have One? • Anyone who chooses DNR, No Code, or AND (allow natural death) • Anyone choosing to limit medical interventions • Consider in “anyone you would not be surprised if they died in the next year” • Initiate in the hospital by time of discharge

12. POLST Form Part A • Resuscitation: Includes EMS: Patient has no pulse and is not breathing • Resuscitate • Do Not Resuscitate • Comfort measures will always be provided

13. POLST Form Part B Medical Interventions: Includes EMS: Patient/resident has pulse and/respirations • Comfort Measures Only: Oral & body hygiene, reasonable efforts to offer food and fluids orally.Other measures to relieve pain and suffering. Privacy and respect for dignity. Transfer only if comfort measures fail • Limited interventions: All care above and consider oxygen, suction, treatment of airway obstruction (manual only) • Advanced Interventions: All care above and consider oral/nasal airway, bag-mask demand valve, monitor cardiac rhythm, medication, IV fluids • Full Treatment/Resuscitation: All care above plus intubation and defib. • Other Instructions:

14. POLST Form Part C Antibiotics (notify physician of new infection) • No antibiotics except if needed for comfort • No invasive (IM/IV) antibiotics • Full treatment • Other Instructions:

15. POLST Form Part D Artificially Administered Fluids and Nutrition: Oral fluids and nutrition must be offered if medically feasible • No feeding tube/IV fluids (provide other measures to assure comfort • No long term feeding tube/IV fluids (provide other measures to assure comfort) • Full treatment • Other Instructions:

16. Discussed with: Patient/Resident Agent of DPOAH Court-appointed guardian Spouse Other (Specify) The basis for these orders is: Patient’s request Patient’s known preference Patient’s best interest Medical futility POLST Form Part E

17. POLST Form Part F • Patient/Resident Preferences as a Guide for this POLST Form • Patient/resident personal values may be expressed orally, in writing (such as an advance directive) or by a surrogate • Copies of advance directives or guardianship documents attached to POLST Form • POLST Form cannot be completed without a conversation between physician and the patient/resident • Change in patient preferences or medical status requires reevaluation of POLST • Person completing the POLST Form must print their name, sign and date the POLST Form

18. Provide Comfort Care • Comfort care measures for the dying patient may include: • Manually open the airway (do not provide positive pressure ventilation with a bag valve mask, pocket mask or endotracheal tube) • Clear the airway (including stoma) of secretions with appropriate suction device • Provide oxygen per nasal cannula at 2-4 l/min • Positioning for comfort

19. Comfort Care Measures - Continued • Splinting • Controlling bleeding • Providing pain medications pertinent to the level of certification/licensure • Providing emotional support • Providing emotional support to the family • Contact patient's physician or on-line medical control if directed by local protocols or if questions or problems arise

20. POLST - Signatures • Documents informed consent process • Requires physician signature • Requires patient/resident or legal surrogate signature • Signatures are most common logistical problems!

21. POLST- Who Fills It Out? • Physician or physician designee • Signatures attest to the informed consent process having occurred • Different facilities designate/train different personnel for this purpose

22. EMS Perspective on POLST

23. Washington State Natural Death Act • 1992 WAC Amendment • DOH Direction • EMS Providers: • Adopt guidelines for EMS personnel • Respond to written DNR orders • Personnel legally recognize prehospital DNR orders

24. EMS Provider Liability Protection • RCW 18.71.210 • Acts and omissions in good faith • Acting in accordance with: • Medical Program Director directives (protocols) • Physician’s medical directive

25. 911 Call Response • Locate POLST Form • Patient ID • Focus on PART A (resuscitation) • Box marked • Focus on PART B (medical treatment) • Boxes marked (memorize treatment)

26. Form Location • In the home • Front of refrigerator • Back of bedroom door • Bedside table • On medicine cabinet • Health care setting • Kept with patient between care settings • Hospital and LTC facility • Medical Chart

27. Validation Check • Patient Name • Date of Birth • Signature Date • Signed • Physician’s dated signature & phone • At least 18 years old

28. Transfer • Original bright lime green form • Transferred with individual to be valid • Health Care Institutions • Keep duplicate copy in permanent medical record upon discharge • Also make copy prior to inter-facility transports

29. Revocation of forms • Patient • Verbally revoking order • Destroying form and/or No CPR bracelet • Physician expressing patient’s revocation • Legal surrogate • Line out “physician orders” • Write VOID then initial

30. Special Situations • Patient requests withhold of resuscitation • Always respected • Valid POLST or EMS-No CPR (form or bracelet) always honored • Family insistent on CPR • Verbal requests not consistent with patient’s directive

31. Special Situations (cont.) • Attempt to honor patient’s decision • Family persists • Initiate resuscitation efforts until relieved by paramedics (for 1st Responders and EMTs) • Advanced life support personnel • Continue treatment • Consult medical control

32. Other DNR Orders • EMS honor • Other health care DNR orders • If any doubt about validity, CPR should be started • Health care facilities DNR orders

33. Other DNR Orders (cont.) • EMS Verify • Physician signature • DNR • Patient’s name • Contact on-line medical control • Withhold CPR only following verification of valid physician-signed DNR order

34. Hospital Perspective on POLST

35. POLST in Hospitals • Hospitals are an ideal place to initiate a POLST form • Sample policies and procedures are available • Form must be visible in chart • Staff must be trained and updated on interaction with other end-of-life documents

36. POLST Rollout Experiences in One Community

37. POLST in Washington-Moving Ahead • Roll out has been by county, coordinated by Department of Health, EMS, and Trauma • Not yet in King County • Each county must take certain steps to prepare for POLST

38. Preparing the Community for a POLST Rollout • EMS service providers trained • Hospital updates policies to address POLST • Nursing homes also update policies--surrogate decision making issue may arise here • Physicians trained (in practice this may be one of the last steps)

39. Preparing the Community for a POLST Rollout-Continued • Training for hospital and nursing home staff, including nursing, social work, spiritual care • Other entities and persons, such as assisted living, adult day health, and estate planning attorneys are educated about POLST • Any other awareness activities that make sense for your community

40. Helpful Hints on Community POLST Rollout • Establish a “Go Date” early on and plan accordingly • Hospitals and nursing homes can meet to draft consistent policies • Consider places where people may want to obtain a POLST--fire stations? • Prior to “Go Date” hold community-wide POLST preparedness meeting

41. POLST Resources-Required Training • Emergency Medicine and Trauma Prevention, Department of Health • Phone (360) 705-6700 • www.doh.wa.gov/hsqa/emtp/ • Provides required EMS service provider training

42. POLST Resources-Forms • Graham Short, Washington State Medical Association • Phone (206) 441-9762 • E-mail gfs@wsma.org • Provides POLST forms once EMS training has occurred

43. POLST Resources-Information, Policies, and Procedures • WSHA and AWPHD web sites contain hospital “End of Life Care Manual” with model policies and procedures and background on POLST • http://www.awphd.org/resources.asp • http://www.wsha.org/publications.htm • Information on POLST in Oregon • http://www.ohsu.edu/ethics/polst.htm

44. THE END POLST QUESTIONS ??