A ReviewAdvance Directives and POLST

6/30/14

Objective

• To Review Highlights of Advance Directives and POLST

• Describe rationale for and use of each document

• Discuss differences between advance directives and POLST

• Define who can be a Pennsylvania Health Care Decision-Maker

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Key Points

• What are the differences between advance directives and POLST

• What are the differences in the powers of a health care agent and a representative

• POLST does not replace an advance directive

• If the choice in Section A of the POLST is for CPR, the choice is Section B, Medical Interventions, needs to be Full Treatment

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Advance Directives

A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.

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Advance Directive Recommendation

• Anyone may face a sudden and unexpected acute illness or injury with the risk of becoming incapacitated and unable to make medical decisions

• Everyone age 18 and older should be encouraged to complete a Health Care Power of Attorney document and to engage in advance care planning discussions with family and loved ones

• An ongoing conversation over the years with your healthcare decision-maker, family, and healthcare provider is very important

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Advance Directives

• PA Act 169 provides for health care decisions to be made for an adult patient through three means:1. A living will (LW)2. A health care agent appointed by the patient (HCPOA)3. A close family member or another to serve as a health

care representative for the patient

• Usually LW and HCPOA are combined in single document

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Advance Directives

• Who can make a directive?

– Adult○ 18 years of age or older○ Graduated from high school○ Married, or○ Emancipated

– Sound mind

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Living Wills

• A written statement of the patient’s personal choices regarding life-sustaining treatment and other end of life care

• Becomes effective when a patient is incompetent and has an end stage medical condition or is permanently unconscious

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Health Care Power of Attorney

• A written document in which a person appoints another to serve as his agent and to make health care decisions

• States when and what decisions an agent may make

• States patient’s preferences and values to guide decision-making

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Advance Directive Examples

www.acba.org/Public/index.asp www.agingwithdignity.org/ 10

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Online Example – Useful Tool for Public

Slides walk you through the process and the user can listen to instructions.

www.prepareforyourcare.org 11

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Above slide shows the five different areas that are covered.It all does not need to be done at one time.

Advance Directive Triggering Event

• Patient is in a state of:

– Incompetency

– End stage medical condition

– Permanently unconscious

*In the Pennsylvania statute, “incompetency” is the term that is used. In practice, the term in often used interchangeably with “lacking capacity”.

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Capacity• Assessment of Capacity– Not always constant or fixed– Not always absolute either/or– Capable for some decisions/not all

• Elements of capacity– Ability to understand situation and that there is a

decision to be made– Able to communicate preference– Able to make a judgment/choice– Able to give rational reason for choice

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Decision-makers

• Health care agents

– Designated in a health care power of attorney

– Authority is usually limited to when patient is incompetent/not lacking capacity

– Not restricted to end-of-life decision-making

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Decision-makers

• Health care representatives may make health care decisions for an incompetent patient/lacking capacity who has:

– No health care agent (or no reasonably available agent)

– No legal guardian of the person

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Decision-makers

• Health care representatives

– May be designated by patient. For example, during the admission process, an adult patient may designate his representative should he become incompetent during his hospital stay

– If not designated, selected from priority list in law

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Decision-makers

If no agent appointed, the law gives priority in this order:

1. Current spouse and adult child of another relationship

2. Adult child3. Parent4. Adult sibling5. Adult grandchild6. Close friend

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This is page one of a document that defines the various power of health care decisions makers. Full document found at POLST website, http://www.aging.pitt.edu/professionals/resources-polst.htm

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Who is the Pennsylvania Decision-MakerQuick Start Guide Health Care Decision-Making*

If the patient is unable to engage in the POLST discussion, it is critical that the conversation occurs with the correct legal decision-maker

• Power to Sign POLST or Agree to DNR– Competent Patient - Yes– Health Care Agent - Yes– Guardian - Yes, but..– Health Care Representative - Yes, but…– Incompetent Patient – No

*Copyright 2012 Robert B. Wolf, Esquire

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Who is the Pennsylvania Decision-Maker

Quick Start Guide Health Care Decision-Making*

•Power to Revoke a POLST or DNR Order– Competent Patient – Yes– Health Care Agent - Yes if signed by Agent - Otherwise maybe– Guardian - Yes, if signed by Guardian– Health Care Representative -Yes, if signed by Health Care Representative

*Copyright 2012 Robert B. Wolf, Esquire

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Who is the Pennsylvania Decision-Maker

Quick Start Guide Health Care Decision-Making*

• Power to Decline Care Needed to Preserve Life– Competent Patient – Yes– Health Care Agent – Yes– Guardian – Yes, if End State Medical Condition (ESMC) or Permanently

Unconscious (PU)– Health Care Representative - Yes, if ESMC or PU– Incompetent Patient - No

*Copyright 2012 Robert B. Wolf, Esquire

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POLST

POLST is designed to honor the freedom of persons with advanced illness or frailty to have or to limit treatment across settings of care.

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What is POLST• POLST is a voluntary process that:

– Translates a patient’s goals for care at the end of life into medical orders that follow the patient across care settings

– Consists of medical orders that are based on a patient's medical condition and his/her treatment choices as established in communication between the patient or the legal medical decision-maker and a health care professional

– Allows health care providers to know a patient’s wishes in the event of a serious illness and to honor them

• In some institutions, the POLST document is used to establish goals of care for all patients

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POLST and Advance Directives

• The POLST is not intended to replace an advance health care directive document or other medical orders

• The POLST process and health care decision-making works

best when a person has appointed a health care agent to speak for them if they become unable to speak for themselves

• A health care agent can only be appointed through a health

care power of attorney

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Who Would Benefit from a POLST

• There are no age specifications. Anyone with – Advanced illness– A serious health condition– Medical frailty– Advanced age and wishing to further define their

preferences for care

• Tool for determination– Ask yourself “would I be surprised if this patient died

within the next year”.

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POLST Form Highlights

• Physician, physician assistant or CRNP medical order

• Standardized form, bright distinct color

• Based on conversation for goals of care

• May be used to limit medical interventions or clarify a request for all medically indicated treatments including resuscitation

• Transferrable across care settings

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POLST, Who Fills it Out?• Physician or physician designee facilitator (RN, NP,

PA, Social Worker)

• Facilitators need to be skilled, knowledgeable and credible to physicians/providers as well as patients and families

• Verbal orders are acceptable with follow-up signature in Pennsylvania in accordance with facility/community policy

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Requirements to Make the Form Valid

• Patient name (date of birth recommended)

• Completion of Section A, resuscitation orders

• Physician/PA/CRNP signature*

• Patient or surrogate signature

• All other information is optional

*In Pennsylvania, a physician assistant signature requires a physician co-signature within ten days.

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Differences between POLST and Advance Directive

Characteristics POLST Advance DirectivePopulation For the seriously ill All adults

Timeframe Current care Future care

Who completes the form Health Care Professionals Patients

Resulting form Medical Orders (POLST) Advance Directives

Health Care Agent or Surrogate role

Can engage in discussion if patient lacks capacity

Cannot complete

Portability Provider responsibility Patient/family responsibility

Periodic review Provider responsibility Patient/family responsibility

Above table based on:Sabatino, Charles; Karp, Naomi, AARP Public Policy Institute, (2011) “Improving Advance Illness Care: The Evolution of State POLST Programs”, http://assets.aarp.org/rgcenter/ppi/cons-prot/POLST-Report-04-11.pdf, p4. 30

Where Does POLST Fit In?Advance Care Planning Continuum

Complete an Advance Directive

Complete a POLST Form

Age 18

Treatment Wishes Honored

Diagnosed with Advanced Illness or a Serious Health Condition (at any age) or Medical Frailty*

Update Advance Directive Periodically

C O N V E R S A T I O N

Materials adapted and used with permission from the Coalition for Compassionate Care of California, www.coalitionCCC.org

*Someone for whom you would not be surprised if they died within a year 31

HIPAA Compliant

Cardiopulmonary clarifies type of

resuscitation. Do Not Attempt Resuscitation

assists clinicians in communicating

odds about success

Clear instruction on

when to transfer to

hospital and use of

intensive care

IV fluids in Limited

Additional Interventions

section

Artificial hydration and

artificial nutrition both

found here

Options give people the choice to decide

later since issue of

when to use antibiotics is complex

Discussion about

treatment preferences is required

If any section left unmarked,

the highest level of

treatment must be provided

Pennsylvania Form

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Section ACardiopulmonary Resuscitation

• In choosing CPR or DNR, patients need understanding of the benefits/burdens

• Television portrayal of CPR unrealistic with 66% surviving. In real life for elderly patients

• 22% may survive initial resuscitation• 10-17% may survive to discharge, most with impaired function

• Chronic illness, more than age, determines prognosis in the elderly – With chronic illness, average survival rate less than 5%.– With advanced illness, survival rates are often less than 1%

• Annals Int Med 1989; 111:199-205;• NEJM.1996; 334(24):1578-82.• JAMA 1990; 264:2109-2110• FAST FACTS AND CONCEPTS # 024 and #179

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Section A CPR and Medical Interventions

• If choosing “Attempt Resuscitation / CPR” in Section A, “Full Treatment” is required for Section B, Medical Interventions

• It is not appropriate to request “Attempt CPR” and “Comfort Measures Only”

• If a person wants CPR, they must be willing to have ACLS (Advanced Cardiac Life Support) guidelines followed, which usually includes intubation and care in the ICU

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Section A DNR and Medical Interventions

• “Do Not Attempt Resuscitation / DNR” may be chosen with any of the medical interventions in Section B

• “DNR” with “Full Treatment”– Can choose to receive aggressive medical interventions, but

doesn’t want to be resuscitated if found without a pulse or not breathing (they have died)

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Diagram of POLST Medical Interventions

CPR

Full Treatment*

DNR

Comfort Measures

Limited Interventions

*Consider time/prognosis factors under “Full Treatment” “Defined trial period. Do not keep on prolonged life support.”

Materials adapted and used with permission from the Coalition for Compassionate Care of California, www.coalitionCCC.org

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POLST and EMS

At top of form it states:

To follow these orders, an EMS provider must have an order from his/her medical command physician.

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Out-of-Hospital DNR

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

orOrders from a medical command physician

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The standardized POLST allows for faster and more efficient discussion between EMS and the medical command physician.

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Currently, the POLST form is not available on the Pennsylvania Department of Health website. It is found at:

Pennsylvania Form 2nd Side

www.aging.pitt.edu/professionals/resources.htm

This side includes:

Surrogate Contact Information

A line for the signature of a POLST

Facilitator who completes the form

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Revocation of POLST Form

• May be revoked by patient at any time

• If patient lacks decision-making capacity, a legal decision-maker may revoke

• Revocation can be a verbal statement

• Draw a line through sections A through E of the invalid POLST

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Transfer• Original pink form

– Transferred with individual (Use of original form is highly encouraged)

– Photocopies and Faxes of signed POLST forms are valid

− It is recommended that copies be made on pulsar pink paper

• Health care institutions– Keep duplicate copy in permanent medical record

upon discharge– Also make copy prior to inter-facility transports

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Key Take Away Points• What are the differences between advance directives

and POLST

• What are the differences in the powers of a health care agent and a representative

• POLST does not replace an advance directive

• If the choice in Section A of the POLST is for CPR, the choice is Section B, Medical Interventions, needs to be Full Treatment

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Acknowledgment

We would like to recognize the Pennsylvania Medical Society

for use of materials from:

“A Guide to Act 169 for Physiciansand Other Providers”

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