What is POLST and Why Should I Care?

COLC Monthly Seminar3 May 2012

Dr. Dan KimballMs. Elizabeth Moreli, ESQ.

What is POLST and Why Should I Care? What Most People Want at End-of-LifeRespect my uniqueness as an individualProvide me with peace and comfortAddress my spiritual needsRecognize my cultural heritageCommunicate with meHelp me with my pain (physical and emotional)Dont prolong my dyingGive me a sense of controlRelieve the burden on my loved onesTouchWhat does POLST mean?P - Physician (or Pennsylvania)

O - Orders for

L - Life

S - Sustaining

T - TreatmentHistory 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 Force44So, What is a POLST form?A document that helps doctors, nurses, healthcare facilities and emergency personnel honor patient wishes regarding life-sustaining treatments in emergency situations. Goal is to improve the quality of care people receive at the end of life by turning Patient Goals and Preferences for care into Medical Orders.

HIPAA Compliant Cardiopulmonary clarifies type of resuscitation. Do Not Attempt Resuscitation assists clinicians in communicating odds about successClear instruction on when to transfer to hospital and use of intensive careIV fluids in Limited Additional Interventions sectionArtificial hydration and artificial nutrition both found hereOptions give people the choice to decide later since issue of when to use antibiotics is complexDiscussion about treatment preferences is requiredIf any section left unmarked, the highest level of treatment must be providedPennsylvania Form66.

7Pennsylvania Form 2nd Side7More 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 individualsWhat 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)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.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.

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 voluntaryLegal Requirements for POLST Form Must include the patients 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).Limitations of POLST completed by someone other than patient or Health Care AgentNeither 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 life unless the patient is in an end-stage medical condition or is permanently unconscious.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

Differences between POLSTand Advance Directives16CharacteristicsPOLSTAdvance DirectivesPopulationFor the seriously illAll adultsTimeframeCurrent careFuture careWho completes the formHealth Care ProfessionalsPatientsResulting formMedical Orders (POLST)Advance DirectivesHealth Care Agent or Surrogate roleCan engage in discussion if patient lacks capacityCannot completePortabilityProvider responsibilityPatient/family responsibilityPeriodic reviewProvider responsibilityPatient/family responsibilityBomba PA, Black J. The POLST: An improvement over traditional advance directives. Cleveland Clinic Journal of Medicine. In press.

Where Does POLST Fit In?Advance Care Planning ContinuumComplete an Advance DirectiveComplete a POLST FormAge 18Treatment Wishes HonoredDiagnosed with Serious or Chronic, Progressive Illness (at any age)Update Advance Directive PeriodicallyC O N V E R S A T I O N17This slide shows where POLST fits into the Advance Care Planning Continuum.Starts at age 18 with completing an AHCD.Your AHCD should be updated periodically check names, contact information, and healthcare wishes.If you are diagnosed with a serious or chronic, progressive illness at any age, talk with your physician about completing a POLST form.The goal is that your treatment wishes are honored.

What is the word along the left side? Conversation. An ongoing conversation over the years with your healthcare decisionmaker, family, and healthcare provider is very important.

Out-of-Hospital DNR

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

1818Checklist 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)Selected ChallengesMeasuring 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.

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POLST Website Resourceshttp://www.aging.pitt.edu/professionals/resources.htm Aging Institute of UPMC Senior Services and the University of Pittsburghwww.polst.org Center for Ethics in Health Care Oregon Health & Science University http://www.aarp.org/ppiAARP Public Policy Institute