Use of the POLST when transferring patients to a long term care facility

Bud Hammes, Ph.D.Gundersen Lutheran Medical Foundation

Need for out-of-hospital DNR orders 1999 Medicare data shows that only

23% of deaths occurred in a hospital in the La Crosse area

Out of 540 deaths over 11 months the median age of death in La Crosse health organizations in 1996 was 82 years

Most deaths in La Crosse occur at home in hospice or in a nursing home

Out-of-Hospital DNR Protocols Emergency services and other

health professionals are expected to attempt CPR unless there is a DNR order!

CPR Outcomes In general pop. 2-15% survival at

discharge from hospital Long term care 0-5% survival at

discharge from hospital

unwitnessed arrest 0% Long term survival 5% Public perception 45-85% success

Hx of area protocols Until 1997 out-of-hospital orders were

written on physician scripts or in facility order sheets.

In 1997 Wis Chapter 154.17 provided for a DNR bracelet.

1997 La Crosse area health organizations agree to use the POLST form to communicate orders to emergency services

Wisconsin DNR Bracelet

Advantages of POLST Available to all patients Is private Deals with a wide range of

emergency treatments Easy to maintain No discomfort to patient

Physician Orders for Life-

Sustaining Treatment (POLST) (page 1)

Success of POLST

Research in Oregon indicates that the use of POLST is effective in limiting care according to preferences of nursing home residents.

Tolle SW et al. A prospective study of the efficacy of the physician order form for life-sustaining treatment. JAGS 46:1097-1102, 1998.

Eleven year comparison of CPR attempts at GLMC

Year # of attempts on pts 55 and >

# alive at discharge

% of survival at 1 year

1989 150 22 14.6%

2000 48 14 29%

Need for Improvement at GL Need to consider if a patient being

transferred to a nursing home for the first time wants CPR attempted in the case of cardiopulmonary arrest. One LTC facility had 16 new

admissions in one month from GL where no consideration of CPR status know upon admission.

Goals for all new transfers Help the patient or the patient’s surrogate

understand and reflect on the issues of CPR

Include information of the conversation and decision about CPR in the discharge summary.

Complete at least section A of the POLST for every patient who does not want CPR attempted in the case of a cardiopulmonary arrest.