The Role of POLST in Advance Care Planning

2. The Role of POLST in Advance Care Planning Financial Disclosure This presenter has no financial interests or relationships to disclose.

3. Objectives At the end of the course, participants should be able to: 1) Recognize how POLST is different from Advance Directives 2) Apply use of POLST in their practice 3) Determine how to respond when a patient has a POLST

4. Dying in America: “The IOM committee believes a person-centered, family-oriented approach that honors individual preferences and promotes quality of life through the end of life should be a national priority.” SEPTEMBER 2015 Improving Quality and Honoring Individual Preferences Near the End of Life. https://www.nap.edu/catalog/18748/dying-in-america-improving-quality-and-honoring-individualpreferences-near

5. End-Of-Life Demographics In The U.S. • The majority of deaths occur in elderly adults • Most deaths occur in the hospital or nursing home • Location of death varies regionally: – Portland: 35% in hospitals – New York City: >70% in hospitals https://www.nap.edu/catalog/18748/dying-in-america-improving-quality-and-honoring-individualpreferences-near

6. Quality Of End-Of-Life In The U.S. Typical deaths are: • Slow • Associated with chronic disease • In persons with multiple problems • Marked by dependency and care needs

7. Quality Of End-Of-Life In The U.S. Quality of life during the dying process is often poor because of: • Inadequate treatment of distress • Fragmented care • Strains on family, support system Difficult decisions about use of life-prolonging treatments are oftennecessary

8. One Conversation Can Make All The Difference. • 70% of people say they prefer to die at home yet • 70% die in a hospital, nursing home, or long-term-care facility. (Centers for Disease Control, 2005) • 82% of people say it’s important to put their wishes in writing ; 23% have actually done it. (Survey of Californians by the California HealthCare Foundation, 2012) • 80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care; 7% report having had an end-of-life conversation with their doctor. (Survey of Californians by the California HealthCare Foundation, 2012)

9. One Conversation Can Make All The Difference • Dying is not just a medical condition but it isa deeply emotional and spiritual experience • The conversation is a blessing for a family • The process is the product:“ Tell me what is most important to you?” • Knowing what is wanted at the end of life is a gift; it may be the last gift we can give our loved one.

10. How Physicians want to die http://thesocietypages.org/socimages/2013/12/31/how-do-physicians-and-non-physicians-want-to-die/

11. Advance Care Planning • "Advance Care Planning Is Not An Event, It's A Process." • - Susan Tolle, Director of the Center for Ethics in Health Care at Oregon Health & Science University Discussion Decision Documentation

12. When Should Advance Care Planning Happen? While individuals are still actively able to participate in the conversation prior to a crisis. “Planning is important! It wasn’t raining when Noah started the ark.” ~ Richard Cushing

13. Advance Care Planning Talk with the patient.Have the surrogate present during the conversation. Try to discern: • If the patient understands his/her situation • What is most important to him/her now • If the patient understands his/her choices • Discussion of trade-offs and “goals of care” • Use “compassionate honesty” • When someone states “I want everything done”, don’t leave it there. Ask them what “everything” means, otherwise, it is NOT informed consent. The reason physicians choose different interventions at end of life compared to non-physicians – they have informed consent. • Document, document, document

14. Gold Standard Discussing and following a patient’s preferences for end-of-life care should be as routine as asking about and responding to a patient’s allergies to medicines.

15. Right to Refuse Medical Treatments • In Georgia, an adult with capacity has the right to refuse any unwanted medical treatment for any reason. • The right to refuse medical treatments includes life support and other life-sustaining treatments. • The right to refuse or terminate treatments may be exercised by appropriate loved ones when a patient has lost capacity to make decisions. Georgia’s law on cardiopulmonary resuscitation. O.C.G.A. §31-39-1 et. seq.

16. History of Advance Care Planning • It is a National movement– Advance Directive– National POLST Paradigm– The Conversation Project • It is a State movement– Georgia Health Decisions– Georgia POLST Collaborative

17. Georgia Advance Directive for Health Care In 2007, Georgia Law combined all three advance care planning tools into one document:• Naming a health care agent• Stating treatment preferences Also includes:• Authorizing organ donation, autopsy, burial Legal with:• Patient signature & 2 witnesses https://aging.georgia.gov/sites/aging.georgia.gov/files/related_files/service/GEORGIA_ADVANCE_DIRECTIVE_FOR_HEALTH_CARE-10.pdf

18. POLST: Physician Orders for Life Sustaining Treatment • Medical order completed by a health care provider– Requires signatures by the patient or patient’s authorized representative AND a physician • Activates a patient’s Advance directive • Mechanism to communicate a patient’s wishes for their care at the end of their life • Designed to travel from one care setting to another • Must be honored by all health care professionals

19. Physician Order for Life Sustaining Treatment (POLST) POLST in action: • Oregon deaths 2011-2012; 17,902 (30.9%) had aPOLST form in the registry • Comfort measure only (CMO) 11,836 (66.1%) -avoiding hospitalization unless comfort cannot be achieved in the current setting • Only 6.4% of participants with POLST CMO orders died in the hospital • Full treatment requested - 44.2% died in the hospital ~ J Am GeriatrSoc 62:1246–1251, 2014.

20. Who Should Have a POLST? • Anyone who wants their end-of-life decisions honored • Anyone choosing “Allow Natural Death”/ “DNR” • Anyone choosing to limit or not limit medical interventions • Anyone residing in a LTC facility • Anyone who might die or lose decision-making capacity within the next year

21. Difference Between Advance Directives and POLST

22. Georgia Legal Foundations • GA Advance Directive– Ga. AD Law - 2007 HB 24– Ga. Dept. Of Human Resources (2007 HB 24 Rules And Regulations)– Ga. Code 31-39 DNR/AND & Cardiopulmonary Resuscitation Laws • GA Physician Order For Life Sustaining Treatment(POLST) – Ga. DPH, POLST Form, 2012– SB 109 2015

23. SB109 (2015) • Portable across care settings • Review of form recommended atcare transitions • Immunity for all when followed in good faith -Except if violates Code Section 16-5-5 (Assisted Suicide) • Protections for treating pain • Equates terms such as DNR=AND • All conflicting laws are repealed • Most recent document is valid one

24. Georgia POLST Form • Developed by the Georgia Department of Public Health in 2012 updated 2015 after SB109 • Available at www.gapolst.org • Use and compliance with POLST form provides immunity to any “person” acting in good faith (2015)

25. Georgia POLST Form Five Sections • Cardiopulmonary Resuscitation (CPR) • Medical Interventions • Antibiotics • Artificially Administered Nutrition & Fluids • Signatures

26. Signatures • Two Required: – Patient & Physician OR – Authorized Surrogate & Physician OR – Two physicians (in special circumstances)

27. POLST Implementation/Usein Hospital Setting Medicare Conditions of Participation: Hospital orders may only be written by MD with staff privileges (this does not mean a POLST signed by a non-privileged physician should be ignored) POLST Process when Patient Arrives at Hospital with POLST signed by non-privileged physician: • Physician should review the document(s) and either • Sign POLST form as the “Concurring Physician” • Rewrite orders into hospital system • Hospital policies should be written to govern this process David W. Eddinger, RN, MPH Captain US Public Health Service, Retired / Technical Director Hospital Survey and Certification CMS/CCSQ/Survey & Certification Group/Division of Acute Care Services

28. Health Care Team Responsibilitiesin ALL Healthcare Settings • To follow the patient’s known preferences • To honor the patient’s Advance Directive and POLST without regard to personal views • If unable to honor preferences, facilitate the transfer of patient’s care

29. Our Vision STATE OF GEORGIA HOSPITAL SYSTEMS COMMUNITY SERVICE AREA LTC SNFs PHYSICIANS OFFICE Home Health Assisted Living Hospice HOSPITAL SETTING WITH ADVANCED CARE PLAN

30. Georgia POLST Collaborative • 40+ statewide organizations • Part of a national movement to promote POLST • Georgia POLST is endorsed by the National POLST Paradigm Taskforce • Vision: All Georgians will have their health care preferences known and honored

31. Georgia POLST Collaborative (cont’d) • Mission: To improve health care at the end-of-life through – Promoting the utilization of the Physician Orders for Life Sustaining Treatment form by health care professionals and institutions across the state – Educating Georgians about advance care planning and the role of POLST in having their wishes honored

32. National POLST Paradigm Programs Mature Programs Endorsed Programs Regionally Endorsed Program Developing Programs No Program (Contacts) www.polst.org *As of January 2016 Programs That Do Not Conform to POLST Requirements

33. CASES

34. Case 1 • 50 yo male, former firefighter • Diagnosis of end stage heart failure with his second Left Ventricular Assist Device (LVAD) •Recurrent line infections • Not a transplant candidate He states, “Doc, how do I get one of those DNR orders?”

35. Section A • This patient has an LVAD = always no pulse; we wrote this in and underlined “not breathing” • Start talking in “POLST terms” • We need to say – “When your heart and lungs stop and you die…” – NOT “Do you want us to do everything?”

36. Section B • Patient wishes DNR/AND • Wants IV diuretics and IV antibiotics for recurrent infections • He chose “limited additional interventions”

37. Section C • This patient with recurrent line infections– Discontinueantibiotics when fully bed bound Who else may want to limit antibiotics? • Data shows that antibiotics may prolong life by a few months, but decreases quality of life significantly in patients with end stage dementia; some patients may agree with oral antibiotics but do not want hospitalization or PICC line for IV antibiotics Heerema, E. (2013). Antibiotic Use in Advanced Dementia. About.com Alzheimer’s/Dementia

38. Case 2 • 45 yo male with ALS and dysphagia, full assist. • He is Catholic and questions if he stops something, will God consider that suicide? • He and his family go on trips and enjoy life.

39. Section D • He refused intubation and trach • Code status of DNR/AND • Received a PEG tube after multiple goals of care discussions and lived nearly two more years. • He wrote in when to stop artificial feeding and fluids in “additional orders” area – when no longer alert and able to participate with his family

40. Case 3 • 80 yo female • End stage renal disease– She does not want dialysis • Wishes to “Allow Natural Death” • Never any machines, especially dialysis • “No nursing home ever!” • Designates a distant relative asMPOA– Does not trust the MPOA to honor her wishes; wants further protection – creates a POLST

41. Additional Orders • The additional orders section – use it to clarify: - No Dialysis Oralversus IV antibiotics BiPapinstead of intubation Time-limited trial of “48 hours or less to see if reversible, otherwise, stop and transition to CMO”

42. Case 4 • 90 yo patient • Multiple co-morbidities and frailty • D/C to LTC • He states “If I told you once, I told you a hundred times, I have a DNR code!!! Can’t you see my wrist band? Don’t you guys look at the chart?”

43. My hospital won’t let me use POLST? • D/C with a POLST form – Georgia law protects and honors the POLST across all healthcare settings – Remember: Delay in time before the physician at LTC sees the patient? • Complete a POLST even if the patient is full code • Educate the EMS crew about POLST • Educate the ER physician • Educate your hospital

44. Case 5 • 87 year old male • Metastatic small bowel cancer • Wishes to “Allow Natural Death” • “Never” wishes to be on any “machines” • Wants to die at home– Lives alone • POLST is created and he wears it around his neck

45. Make patients POLST advocates • Patient told everyone (friends, family, neighbors) what his pink form around his neck was and what it meant When he had an emergency and EMS arrived he asked each EMS person if they understood what it meant and made them promise to honor it When he came to the ER, he did the same with all ER staff and then later, when admitted, his hospitalist and nurses Then his subacute rehab attending and staff He came home on hospice and died in his sleep after a good meal with friends and a glass of wine

46. Make patients POLST advocates • POLST is new in the state of Georgia • Empower patients to advocate for POLST– Put it on the fridge– Carry copies because they are valid • Tell loved ones what it is and why you have it • Explain to doctors and nurses– Turn form over and point to the GA policy that protects them • Explain to patient they may rip it up – it is their order

47. Case 6 • EMS is called to the home of a 60 yo female by a neighbor that sees the patient through the window; she is down on the floor • Once inside, EMS sees a pink form on the patient’s fridge •They look at the form, it has a signature in the patient section and physician section • The form states ‘AND’ and ‘Limited Interventions’ - The patient has a weak pulse and shallow breathing - O2 with mask is placed - IVF with NS started; patient is taken to the hospital -EMS hands over the POLST form to the ER staff

48. ER and hospital staff • The ER nurse and physician see the POLST and review the form • The ER physician decides to co-sign the POLST in case she gets pulled away before entering the order into the chart • The ER physician then enters the order into the hospital chart • The patient wakes up in the hospital and the hospitalist verifies that the POLST order is correct – the patient states “yes, I’m so glad it worked!” • Her nephew in California is her MPOA and he is called and updated at her request • The patient leaves to go to a SNF for rehab and later LTC (she can no longer live alone). The POLST goes with her.

49. SNF and LTC staff • The intake nurse sees the POLST, he remembers his training and places it on the front of the patient’s chart and the back of the door in the patient’s room based on what his facility has decided • The SNF has created a checklist of what to do with a POLST which includes letting all other staff know of the patient’s POLST form in each sign-out • The attending sees the patient days later and co-signs the form • The patient has an event at 3am on a Saturday; the clerk calls EMS but lets them know patient has a POLST – patient goes to hospital again with POLST • The patient is no longer alert, her nephew(and MPOA) arrives from California; her POLST is still being followed • The patient transitions to hospice at the LTC facility for her diagnosis of metastatic cancer; the POLST is reconfirmed by the hospice intake nurse

50. Case 7 • 80 yo patient found at home in cardiac arrest • POLST is on the fridge, section A states Allow Natural Death/Do Not Resuscitate • EMS is called to the scene •While the EMS team assesses the patient, the first responder sees the pink form on the fridge and brings it to the team. The patient has signed and a physician has signed. • A family member is present crying, “do something!” • The paramedic talks to the loved one explaining that this form is a medical order directing them NOT to attempt resuscitation. It is a direct order from the patient and the patient’s doctor and must be honored. Empathy and support is offered.