Minnesota’s Provider Order for Life Sustaining Treatment polstmn

1. Minnesota’s Provider Order for Life Sustaining Treatmenthttp://www.polstmn.org Edward Ratner, MD Associate Professor of Medicine, University of Minnesota Chair, Minnesota POLST Task Force ratne001@umn.edu October, 2010

2. Learning Objectives To be able to: • Describe POLST in Minnesota • Assist medical providers by completing POLST documents for their signature • Appropriately follow POLST when signed by eligible medical providers

3. Purpose of POLST in Minnesota • Communicate from medical provider to EMS, ER, nurses, doctors, and home care nurses. • Operationalizes written advance directive and surrogate statements • To inform until AD or surrogate can be re-consulted (e.g. 24-48 hours) • For those in last one to two years of life

4. Minnesota POLST History • Considered since 1990’s • Hennepin County since mid 1990’s • Minnesota Medical Association Ethics Committee Considered ~ 2006 • POLST Task Force – 2007-09 • Implemented by Minnesota health systems in 2010

5. Minnesota POLST Form • Title: “Provider Order….” (not physician) • Section A: Cardiopulmonary Resuscitation • CPR versus DNR, aka Allow Natural Death • Section B: Goals of treatment • Comfort care only; hospitalization alternatives? • Limit interventions such as intubation; treat of reversible illness or injury • Provide life sustaining treatment • Section C: Interventions and treatment • Antibiotics • Hydration • Nutrition

6. Minnesota POLST Form (continued) • Section D: Summary of goals • Discussed with: patient, healthcare agent, other, none • The basis for these orders is patient’s: request, known preference, healthcare directive or living will, best interest, other • Contact information of form preparer • Section E: Signatures • Provider signature (required) • Patient or health care agent/guardian/surrogate

7. Completing a POLST in a senior housing setting • Can be performed by RN, SW, chaplain • Best if based on discussions with patient or legal surrogate • May not be accepted by medical providers if based on: • “Known preference” or “Best Interests”, unless through legal surrogate • Interpretation of Health Care Directive only

8. POLST Signatures • RN/SW/Chaplain name and signature required • Patient/Surrogate signature valuable but not required • Send copy of POLST to MD/NP/PA for signature • with Health Care Directive, if available

9. HCD and POLST • If POLST completed based upon HCD, medical provider has legal protection when preferences honored. • If patient competent, do both (if L.E. < 2 yrs) • Without HCD, POLST clarifies and communicates – but not legally protective

10. Following a POLST in Senior Housing • Requires institutional policy and procedure • CPR/DNR applies only if pulseless • Comfort Care – comfort orders + options to avoid (not forbid) evaluation by EMS or ER

11. Following a POLST (continued) • Intubation – rarely relevant • Provide L.S.T. - call 911 & transport to ER for acute, severe problems • Antibiotic options helpful for acute fever management • Nutrition/hydration options important in end-stage neurological disease

12. Summary • After long wait, Minnesota has POLST • POLST complements ADs near the end of life. • Home care professionals have multiple roles related to POLST • Forms available at http://www.polstmn.org