What is POLST and Why Should I Care?

1. What is POLST and Why Should I Care? COLC Monthly Seminar 3 May 2012 Dr. Dan Kimball Ms. Elizabeth Moreli, ESQ.

2. What Most People Want at End-of-Life • Respectmy uniqueness as an individual • Provide me with peace and comfort • Address my spiritual needs • Recognize my cultural heritage • Communicate with me • Help me with my pain (physical and emotional) • Don’t prolong my dying • Give me a sense of control • Relieve the burden on my loved ones • Touch

3. What does POLST mean? P - Physician (or Pennsylvania) O - Orders for L - Life S - Sustaining T- Treatment

4. History of POLST in PA • 2000 - Provider Task Force to Improve Care at the End-of-Life convened • 2002 - Pittsburgh End of Life Collaborative, a quality improvement initiative within fourteen nursing homes. Funded by Highmark, UPMC and the Jewish Healthcare Foundation • 2004 - Susan Tolle MD, of the Oregon Health Sciences University Department of Ethics and a leader in the launching of POLST, spoke to group of community leaders • 2004 - Coalition for Quality at the End of Life (CQEL) established • 2006 – Passage of Act 169 • 2007 - As mandated by Act 169, the Pennsylvania Department of Health Patient Life-Sustaining Wishes Committee convened • October 2010 - POLST approved by Pennsylvania Secretary of Health • January 2011 - Endorsed by the National POLST Paradigm Task Force

5. So, What is a POLST form? A document that helps doctors, nurses, healthcare facilities and emergency personnel honor patient wishesregarding life-sustaining treatments in emergency situations. Goalis to improve the quality of care people receive at the end of life by turning Patient Goals and Preferencesfor care into Medical Orders.

6. Pennsylvania Form HIPAA Compliant Clear instruction on when to transfer to hospital and use of intensive care Cardiopulmonary clarifies type of resuscitation. Do Not Attempt Resuscitation assists clinicians in communicating odds about success IV fluids in Limited Additional Interventions section Options give people the choice to decide later since issue of when to use antibiotics is complex Artificial hydration and artificial nutrition both found here If any section left unmarked, the highest level of treatment must be provided Discussion about treatment preferences is required

7. Pennsylvania Form 2nd Side .

8. More about POLST forms • This is a voluntary process! • For individuals with advanced chronic progressive illness and/or frailty! (I would not be surprised if this patient were to die within the next 12 months) • For individuals who desire to further define their preferences for care in their present state of ill-health • This is an extension of the Advance Directive Process for appropriate individuals

9. What issues are included in POLST? • Preferences related to Resuscitation • Preferences for levels of Medical Care • Preferences for the use of antibiotics • Preferences for the use of artificial administration of fluids and/or nutrition (i.e., IV fluids and/or feeding tube)

10. Who Completes the POLST Form? • Physician, Nurse Practitioner, Physician Assistant can complete but must sign the form. • Actual completion of the form may be done by other health professionals (i.e., nurses, social workers) • Completed only after an appropriate discussion with the patient and/or surrogate decision maker. • The document is also signed by the patient or the surrogate decision maker. • It then becomes a “Medical Order” that can be understood and followed by other professionals.

11. Where can POLST be used? • Remains with patient in their setting (home, hospice, skilled nursing facility, long term care facility, personal care facility, or hospital). • In facility, form kept on “medical chart” or record! • At home, kept in prominent place (refrigerator, bedside table, or medicine cabinet). • Travels with patient where ever they go! • The bright pink color is to make the form obvious to any professional picking up the chart.

12. A POLST form is not…. • An Advance Directive (you can execute a POLST without a preceding Advance Directive) • In conflict with the Advance Directive • To take the place of a Health Care Agent • To take the place of a Health Care Representative • Required by any institution, law or regulation; it is completely voluntary

13. Legal Requirements for POLST Form • Must include the patient’s name. • Section A (Resuscitation status) must be completed. • Signature by Physician, CRNP or PA. • Physician countersignature for CRNP and PA. • Sections B, C and D are optional. • Patient Signature preferred (institutional guidance).

14. Limitations of POLST completed by someone other than patient or Health Care Agent Neither a health care representative (as distinguished from a health care agent or health care power of attorney) nor a guardian of the person may decline care necessary to preserve lifeunless the patient is in an end-stage medical condition or is permanently unconscious.

15. Suggestions for Periodic Review of POLST • Yearly or semi-yearly (institutional guidance will control); at plan of care meetings, etc. • With any significant change in health status • With change in care setting or level of care • With change in patient preferences for care • At request of patient or patient surrogate decision maker • Improved patient condition • Advance worsening condition to permanent unconsciousness

16. Differences between POLSTand Advance Directives Bomba PA, Black J. The POLST: An improvement over traditional advance directives. Cleveland Clinic Journal of Medicine. In press.

17. Where Does POLST Fit In? Advance Care Planning Continuum Age 18 Complete an Advance Directive C O N V E R S A T I O N Update Advance Directive Periodically Diagnosed with Serious or Chronic, Progressive Illness (at any age) Complete a POLST Form Treatment Wishes Honored

18. EMS providers may only follow a PA OOH-DNR order, bracelet, or necklace Out-of-Hospital DNR

19. Checklist for POLST Program • Policy Development by all Healthcare Facilities • For Advance Directives and POLST • Process for Review of both and addressing conflicts • To accept POLST orders from transferring facility • Education Plan (Staff; Physicians; Patients) • Notification of key contacts (EMS; Hospitals) • Program Implementation (new pts; partial use; full use) • Quality Improvement (Audits and feedback)

20. Selected Challenges • Measuring the quality of the conversation underlying ACP and POLST. • Training health care providers (Facilitators). • Decision-making for those who have no appointed proxy. • Educating health care agents/proxies. • Evaluating protections for vulnerable population.

23. POLST Website Resources