POST FORM

1. POST FORM How does this affect me?

2. Tennessee’s Health Care Decision Act • In 2004, the Health Care Decision Act was passed thus revising Tennessee law concerning health care decision making.

3. What does this act do? • Protects patient’s right to make own health care decisions • Promotes Advance Directives • Reduces court involvement • Defines legal protection for those who uphold

4. Types of Advance Directives • Durable Power of Attorney for Health Care/Appointment of Health Care Agent • Living Will/Advance Care Plan • POST form/ Universal DNR

5. How POST form came about? • Tennessee needed one form to address DNR and other resuscitative services • Tennessee needed one form utilized by all healthcare entities in the state i.e. EMS, Nursing Homes, Hospitals, etc. • Tennessee needed a universal form which could travel and be recognized across state lines

6. Purpose of POST • To provide a mechanism to communicate patients’ preferences for end-of-life treatment across treatment settings • To improve implementation of advance care planning

7. Basis of POST Encourages discussion with patient and family or surrogate decision maker of key end-of-life care issues

8. Impact of Tennessee Law • Acknowledged “Universal Do Not Resuscitate Order” • Means a written order that applies regardless of the treatment setting and that is signed by the patient’s physician which states that in event the patient suffers cardiac or respiratory arrest, cardiopulmonary resuscitation should not be attempted. • The law also indicated the Board for Licensing Health Care Facilities shall promulgate rules and create forms regarding procedures for the withholding of resuscitative services from patients T.C.A. 68-11-224 (e), (5) & (i), (1)

9. What is POST? • POST – Physician Orders for Scope of Treatment • What purpose POST form serves • Standardized form containing orders by a physician who has personally examined a patient regarding that patient’s preferences for end of life care • Complements, but does not replace Appointment of Health Care Agent &/or Living Will/Advance Care Plan • Effective immediately upon order written and when all requirements met • Requirements for valid POST: • Patient’s name and signature (Patient signature optionalaccording to facility policy) • Orders • Physician’s signature (MD/DO) • Basis for orders

10. POST Form Description • POST Form format • Top of Form • Explanation of form • Any section of form not completed indicates full treatment for that section • When need occurs, first follow orders, then contact physician • Patient’s Name/DOB

11. POST Description cont. • POST Format cont. • CPR: Code or No Code? • Level of intervention (i.e. comfort measures, limited additional interventions, and full tx) • Comfort care level stipulates: “Not to be hospitalized unless comfort interventions in the present setting fail” – as applicable to the facility patient/resident is located in • Use or withholding of antibiotics, IV fluids, and feeding tubes

12. POST Description cont. • POST Format cont. • Check 1 box each section • SECTION A: Code Status • Resuscitate or … • Do Not Attempt Resuscitate If neither is marked, patient is to be resuscitated

13. POST Description cont. • POST Format cont. • Section B: • Medical Interventions • Comfort Interventions: Treat with dignity and respect. Keep clean, warm, dry. Use medication by any route, positioning, wound care & other measures to relieve pain/suffering. Use oxygen, suction, manual tx of airway obstruction as needed for comfort. Do not transfer to hospital for life sustaining tx. Transfer only if comfort needs cannot be met in current location. • Limited additional Interventions: Includes care described above. Use medical tx, IV fluids and cardiac monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care.

14. POST Description cont. • POST Format cont. • Full TX: All above plus CPR, intubation, defibrillation • Other instructions_______________

15. POST Description cont. • POST Format cont. • Section C: Antibiotics • Treatment for new medical conditions • No antibiotics • Antibiotics • Other instructions____________

16. POST Description cont. • POST Format cont. • Section D: Medically Administered Fluids & Nutrition • No IV fluids • IV fluids for a defined trial period • IV fluids long term • No feeding tube • Feeding tube for a defined trial period • Feeding tube long term • Other instructions__________

17. POST Description cont. • POST Format cont. • Where does the Physician Sign? • Section E: • By a physician who has examined the patient (Mandatory) • Discussed with…. • Physician’s printed Name/Phone # • Basis for Orders • Patient’s preferences • Patient’s best interest (Patient lacks capacity or preferences unknown) • Medical indications • Other (specify)

18. POST Description cont. • POST Format cont. • Required Signatures: • Patient/legal rep, surrogate (Patient’s signature isoptional according to facility policy) • Person preparing form • Title/phone number/date Back of Form: • Directions for Health Care Professionals: • Completing POST • Using POST • Reviewing POST

19. Who Can Fill Out POST Form? • Physician • Social Worker – experienced in a health care setting • Nurse • MD signs regardless who completes and must discuss form and contents with patient/responsible party

20. Need POST if has DNR Order? • POST addresses more than just DNR - Addresses… Comfort level IVs/Nutrition Antibiotics Documents what individual was involved in discussion Signature of pt, parent, or guardian or Health Care Agent

21. POST is for… • Seriously ill patients* • Terminally ill patients * chronic, progressive disease/s

22. Is POST required on all patients? • NO on admission • Voluntary • Specifically focuses on medical treatment patient does or does not want at end of life • YES on transfer to another health care facility

23. What if Patient already has Advance Directive? • POST reinforces wishes expressed in advance directive • POST is a physician’s order that should be immediately used to direct the care of the patient • Recommend very ill patients have both, POST & Advance Directive

24. Need DNR order if have POST? • POST serves as the DNR order

25. When Should Form be Reviewed? • When patient is transferred from one health care facility to another • Facility initiating transfer must communicate the existence of POST form to receiving facility PRIOR to transfer (POST form must accompany the patient to the receiving facility) • POST orders remain in effect in receiving facility • After admission, attending MD should review & a healthcare professional should initial POST • If patient’s condition significantly changes, such as: • Close to death • Extraordinary suffering • Improved condition • Advanced progressive illness • Permanent unconsciousness • When patient’s preferences change

26. Changing the POST Form • Void the form; complete a new one • How to Void the POST • Draw a line through the Physician Orders • Write the word “VOID” in large letters, then • Sign or initial the form • After voiding the form, a new form may be completed – leave VOIDED form in permanent record • If no new form is completed, full treatment & resuscitation may be provided

27. Must Health Care Comply with POST Form? • YES • Providers can be disciplined by their licensing board for failure to honor advance directives or decisions of surrogate, provided provider had actual knowledge of directive • Law protects good faith compliance with honoring Advance Directives

28. Why POST Works • By law MUST accompany patient • Contains specifics • It IS a physician’s order – no interpretation is needed and POST orders are to be followed

29. Take-Home Messages (about POST Form) • POST provides a better means to identify and respect patient’s wishes • POST completions will improve end-of-life care throughout the system • Use of POST will require communication to make it work in your community • “Where’s the POST form?” • www.tennessee.gov/health • www.endoflifecaretn.org