POST…. P hysician Orders for Scope of Treatment

1. POST…. Physician Orders for Scope of Treatment Respecting Patients’ Wishes at the End of Life Friendship Staff Training

2. An Index Case Mr. Jan, a 71-year-old male with severe COPD and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing SOB and decreasing LOC over 24 hours. The nursing facility staff called EMS who found the patient unresponsive, with a RR of 8 and an O2 sat at 85% on room air. Although Mr. Jan had discussed his desire to forgo aggressive, life-sustaining measures with his family and nursing personnel, the nursing facility staff did not document his preferences, inform the emergency team about them, or mention his do-not-resuscitate order.

3. After EMS was unable to intubate him at the scene, they inserted an oral airway, bagged, and transported the patient to the emergency department (2nd hospital). Mr. Jan remained unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P of 105 , RR of 8, and an O2 sat of 88% despite supplemental oxygen. He had diminished breath sounds without wheezes, and a chest X-ray showed large lung volumes without consolidation. Arterial blood gases showed marked respiratory acidosis. The emergency department physician wrote, “full code for now, status unclear.” The staff intubated and sedated Mr. Jan and transferred him to the intensive care unit. Lynn, et al. Ann Intern Med 2003;138:812-818.

4. What went wrong?(Could this happen in Roanoke?) • Advance directives not documented • DNR order not communicated in transfer • Fragmentation in care (2 hospitals) • Overtreatment against patient’s wishes • Unnecessary pain and suffering • System-wide failure to respect pt’s wishes • Failure to plan ahead for contingencies • No system for transfer of plan

5. What is POST? • A physician order • Can be completed by a non-physician provider but must be signed by qualified MD or DO (Osteopath) • Complements, but does not replace, advance directives • Voluntary use • Recognized by EMS as a valid DDNR

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

7. 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

8. Expected Outcomes of Using POST Process • Improved continuity of care—Form transferable across treatment settings • Clearer communication of wishes • Reduced hospitalization and inappropriate life-sustaining treatments • Fewer EMS transports • More accurate representation of preferences • Higher adherence to wishes by medical professionals.

9. Living Will* v. POST Living Will POST For the seriously ill Decisions among presented options Checking of preferred boxes Stays with the patient A physician’s order to be followed • For every adult • Requires decisions about myriad of future treatments • Clear statement of preferences • Needs to be retrieved • Requires interpretation *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42.

10. Why POST Works… • MUST accompany patient • Contains specifics • Physician’s order—no interpretation is needed • POST orders are to be followed

11. Prompt for POST Completion Would you be surprised if this patient died in the next year?

12. POST: Who Should Have One? • Anyone choosing “Do Not Resuscitate” • Anyone choosing to limit medical interventions • Anyone eligible/residing in a LTC facility • Anyone who might die within the next year

13. Communication across Settings The health care facility initiating the transfer shall communicate the existence of the POST form to the receiving facility prior to the transfer. The POST form shall accompany the person to the receiving facility and shall remain in effect. POST Project Policy and Procedure

14. POST Can Be Completed In Many Settings

15. Let’s Review • True/False • If a patient has a living will they don’t need a POST form.

16. Let’s Review • False. A living will is a more generalized statement of wishes. A POST is physicians orders for specific care wishes of the resident and these orders must be followed

17. Let’s Review • Which residents are candidates for completing a POST form?

18. Let’s Review • A POST form is appropriate for residents who • Are terminally ill • Are seriously ill with a progressive, chronic disease • Are not expected to live more than a year

19. POLST is Spreading California, Georgia, Kansas, Missouri, New Mexico, Utah, Virginia, Washington, West Virginia, Wisconsin, New York, North Carolina, Maryland, Pennsylvania * * * * * * * * * * *

20. POST Pilot Project • POST orders legally recognized in several states, including West Virginia. • 8 regions in the state are conducting POST pilot projects over the next 2 years. • Plan to make POST a uniform document recognized throughout Virginia.

21. Who is Participating in the Pilot? • List your participating pilot project groups here

22. EMS Participants • List your participating EMS and transport groups here

23. POST Form

26. Section A: Resuscitation • Only section applicable to EMS • DNR orders only apply if a person is pulseless and apneic • POST recognized as a valid Virginia DDNR • OEMS approval (Michael Berg) 26

27. SectionB • Review care plan to be sure that palliative care measures available • Institute palliative care measures as needed • If meets admission criteria consider hospice

28. Limited Additional Measures Includes comfort care described in previous section. However, may also use medical treatment, 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. Full Treatment Includes care described in 2 previous sections. Use intubation, advanced airway interventions, mechanical ventilation, and cardiac defibrillation, as indicated. Transfer to hospital, if indicated. Include intensive care, if indicated. Section B: Level of Medical Interventions

29. Comfort Measures Treat with dignity and respect. Keep clean, warm, and dry. Use medication by any route, positioning, wound care and other measures to relieve pain. Do not transfer to the hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Section B: Level of Medical Interventions

30. Section C: Antibiotics Example of “Other Instructions”:Antibiotics may be used only as needed for comfort. (E.g., patients susceptible to UTI’s may reserve right to be treated with antibiotic for pain and discomfort.)

31. Section D: Artificial Nutrition/Hydration • These orders pertain to a person who cannot take fluids and food by mouth. • IV Fluids or Feeding Tube for Defined Trial Period: • Gives option of trying either of these to determine benefit to patient and/or for recovery from stroke or hydration from vomiting, etc. • Recommended trial for IV fluids = 2 to 7 days • Recommended trial for Feeding Tube = 30 days or less 31

32. Section E: Participants & Physician Signature 32

33. Related EOL documents, if any, e.g., Living Will Signature of Patient or Legal Representative Signature of ACP Facilitator Directions for Health Care Professionals Section F: POST Reviews & Instructions

34. POST Form Shall Always Accompany Patient/Resident When Transferred or Discharged!* * Note: Preferable to transfer with original current copy, but legible copies are to be honored as though they are the original. On the top of the transfer packet!

35. “Where is the POST form?”

36. At Transfer • The yellow POST form placed in a red envelope with a label and placed at top of transfer documents: • “POST Order Form---This Form is to Accompany the Resident Upon Transfer or Discharge; if resident returns to (name of facility), please return this form to: (address of facility) • EMS, hand this envelope to person in charge of receiving resident/patient transfer documents.

37. Let’s Review • What color is the POST Form? • True/False: In order for a POST form to be valid, it must be signed by an MD or DO licensed in Virginia • True/False: EMS will not recognize the POST form as a valid DDNR

38. Let’s Review • Section A of a resident’s POST form says he wishes to not be recussitated. Section B of a resident’s POST form indicates that the resident wants Comfort Measures. You find the resident unresponsive, has shallow respirations with long periods of apnea, and a pulse of 100. What should you do?

39. Let’s review • As long as the resident’s comfort can be provided for at the facility, this resident is not to be transferred to the hospital. • How would you handle it, if a family member were insisting that you send the resident to the hospital?

41. How to Complete a POST Form • Must be completed by a health care professional who has been trained as a POST Advance Care Planning Facilitator (ACPF). • Must be based on patient/resident preferences • Must be signed by an MD or DO

42. Why an Advance Care Planning Facilitator (ACPF)?

43. Why an ACPF? • Has received training in having discussions with patients and POA’s about preferences for EOL care • Training was based on our POST form • The Advance Care Planning process takes about 45 minutes and often involves follow-up and/or additional sessions • It is important that POST form is not just a check off sheet---an ACPF can make sure people know and understand their options

44. Who are the Trained ACPF’s at Your Facility/Organization? • List names of trained ACPF here

45. Steps to Starting POST ProcessFor the Resident • List steps for your facility here

47. Upon Transfer/Discharge of a Resident with POST FormList your facility’s procedure here • Prior to discharge/transfer to another care setting, the resident’s nurse or social worker arranging the transfer will notify receiving facility by telephone call of POST form. • Put original POST form into a labeled red envelope and place at top of transfer documents. • Unit Support: Make sure a photocopy of the current POST form is in Advance Directives section of the resident’s chart

48. Envelope Label ORIGINAL POST/DDNR Forms Enclosed Forms are to accompany Resident upon Discharge/Transfer PLEASE RETURN ORIGINAL FORM IN THIS ENVELOPE TO: Friendship Health and Rehab Center 327 Hershberger Rd., NW Roanoke, VA 24012

49. The Red Envelope for Transfer/Discharge

50. Let’s Review • Where does the current original copy of the POST form go in the chart? • Who may help a resident/POA complete a POST form? • What do you do if a resident with a POST form is to be transferred to another health care setting or home with hospice care?