Physician Orders for Life Sustaining Treatment (POLST):Past, Present and Future

POLST: Past, Present and FutureAnswering Your Questions About Illinois’ POLST

Program

Supporting National Healthcare Decisions Day, April 16

Julie Goldstein, MD polstil.org

April 9, 2014

• Dr. Goldstein is receiving no monetary reimbursement for this presentation.

• Apart from her role as chair of the POLST Illinois Taskforce, Dr. Goldstein is also certified State Faculty for the Respecting Choices® Physician Orders for Life-Sustaining Treatment Paradigm Program.

• Respecting Choices® is one of many programs available for POLST training and is not specifically endorsed by the POLST Illinois Taskforce.

Conflict of Interest

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• The legislation that covers the use of the IDPH Uniform DNR Advance Directive/POLST form in Illinois does not provide guidance in all areas.

• The views expressed during this webinar represent the POLST Illinois Taskforce’s current assessment based on available information.

• Dr. Goldstein is not providing legal or medical advice. Please consult your institution’s legal counsel when appropriate.

Disclaimer

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• Brief overview and history of POLST – for more detailed information visit www.polstil.org

• Participant polls conducted throughout the webinar to help us gauge level of use and understanding

• Review commonly asked questions (top 20 with answers are posted on website)

• Participant questions• Follow up slides incorporating additional questions

from the call will be made available

Agenda

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• In March, 2013 Illinois modified the “IDPH Uniform DNR Advance Directive” to bring it closer to the National POLST paradigm standards used in other states.

• In this presentation, “POLST” is being used to refer to the form as shorthand.

• POLST stands for “Physician Orders for Life-Sustaining Treatment”.

Background

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POLST Use in the United States

Mature Program

Endorsed Program

Developing Program

No Program

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Benefits of IDPH DNR/POLST in Illinois

• Promotes patient-centered quality care • Concrete medical orders that must be followed

by healthcare providers • Follows patient from care setting to care setting• Reduces medical errors by improving guidance

during life-threatening emergencies

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The POLST program is designed for:

Patients facing life-threatening complications, regardless of age; and/or

Patients with advanced frailty and limited life expectancy; and/or

Patients who may lose the capacity to make their own health care decisions in the next year (such as persons with dementia); and/or

Persons with strong preferences about current or anticipated end-of-life care.

POLST is NOT for everyone!

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Healthy and Independent

Advancing Chronic Illnesses and Functional

Decline

Multiple Co-Morbidities and Increasing Frailty

Advance Care Planning IS for Everyone!ACP Life Cycle

FIRST PHASE: Complete a PoA. Think about wishes if faced with catastrophic neurological injury.

NEXT PHASE: Consider if, or how, goals of care would change if interventions resulted in bad outcomes or severe complications.

LAST PHASE: End-of-Life planning - establish a specific plan of care using POLST to guide emergency medical orders based on goals.

Document on Power of Attorney form

Document on IDPH DNR form

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POLST promotes quality care through informed end-of-life conversations and shared decision-making:

• Improve conversations, then translate wishes into actionable medical orders

• Encourage quality conversations by skilled persons with proper training (as determined by institution)

• A process, not a single conversation

• Allows the patient more time to think about future scenarios and discuss them with family, friends and care providers

Promoting Patient-Centered Care

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POLL:

Is Your Organization Completing POLST forms with Patients?

Answers:FrequentlyOccasionallyNever

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The IDPH DNR/POLST Form in Illinois

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The POLST FormComfort care for all patients at all times!

3 Primary Medical Order Sections:

A. CPR for Full Arrest, Yes or No• CPR/DNR applies to persons who have died (unconscious, no heart beat, not breathing)• DNR does not imply the person wishes to limit treatment when still alive

B. Orders for Pre-Arrest Emergency• Treatment for patients who are having emergency deterioration but are not dead• Level of care treatment plans, which can be thought of as “Strictly Comfort Care”,

“Limited but Noninvasive Medical Interventions”, or “Full Treatment with all Medically Indicated Treatments”

C. Artificial Nutrition• Acceptable, Trial or Never

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Proposed Changes:• P in POLST would stand for “Practitioner”; expands who may

execute the POLST form to include advanced practice nurses, physician assistants and some medical residents.

• Removes “Advance Directive” from title; form complements advance directives as a translational tool, addresses specific medical circumstances with the actionability of a medical order.

• Adds “POLST” to “DNR” in formal title; patients may use form to request CPR rather than to request DNR.

Proposed Legislation: SB 3076 and HB ?

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Questions…

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Q: Are we required to follow the orders on the POLST form?

A: YES! Licensed hospitals, EMS and long-term care facilities must honor the IDPH Uniform DNR Advance Directive/POLST document.

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“A health care professional or health care provider, or an employee of a health care professional or health care provider, who in good faith complies with a do-not-resuscitate order made in accordance with this Act …may not be found to have committed an act of unprofessional conduct.”

- Subsection (d) of Section 65 of the Health Care Surrogate Act, 755 ILCS 40/65

Following POLST Orders

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Q: If the POLST form is considered a medical order, is it still

necessary to get a separate order for a DNR?

A: The instructions on a POLST form must be followed as outlined. It is up to individual institutions to determine if additional formats will be used to communicate DNR orders within the institution.

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Q: Is the POLST form active upon patient signature, or does it require a physician’s signature?

A: The form is not considered a medical order until the physician has signed it.

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Q: Since the order is not valid until a doctor signs the form, how do you handle telephone orders?

A: This is based on the policies established within your own institution. If your institution has a policy that allows for telephone orders, then you can accept a POLST order over the phone. The physician should physically sign the form as soon as possible.

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Q: What should I do with previous IDPH DNR forms?

A: The old DNR form is still valid! Review it with the patient. If a POLST form is more appropriate for the patient after careful conversation with a health care worker, complete a POLST form. The updated IDPH DNR/POLST form is a better form and should be used moving forward.

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Q: Why isn’t removing “DNR” being proposed in the legislation for the revised POLST form?

A: In the state of Illinois, we started with a DNR form. The form was then changed to the IDPH Uniform DNR Advance Directive . There are

legislative rules and reasons why this term needs to stay in the title for now.

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Q: I was under the impression that the POLST form is only for pre-

hospital, and does not apply for patients in the hospital. Is this true?

A: Yes, the POLST form is meant to serve as instructions for first responders. It also represents the wishes of the patient

which are translated into a medical order set. So the instructions that are put into place on the POLST form still apply, unless reconsidered by the patient/substitute decision-maker, even as the patient moves into the hospital and to other healthcare settings.

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Q: Should all residents in a nursing home have a POLST form?

A: Completing a POLST form is voluntary

• Using a POLST form is a practical way to capture both medical orders and patient preferences, but cannot be required• Residents typically meet criteria for using the form• All staff should be trained on the form• Everyone should know what to look for on the form

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POLL:Has anyone in your organization been formally trained on how to have a POLST

conversation?

Answers:Yes, two or more staff have been trained to facilitate a POLST conversation and complete the form

Yes, one staff member has been trained to facilitate a POLST conversation and complete the form

No

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Q: When explaining the POLST form to our residents, they tell us they want to try CPR, but don’t want

any machines. How do we respond to that?

A: Part A of the form is an instruction regarding treatment of a patient who has died, who is in “cardiac arrest”, meaning: No heartbeat, No respirations , No consciousness. If a person wants resuscitation attempted when dead, intubation will almost always be a component of this treatment if resuscitation is successful.

In Part B, the intubation that is being described is in the context of respiratory distress or pending respiratory failure, rather than in the context of cardiac arrest.

Most people who express these wishes are not aware that 1) intubation/mechanical ventilation is almost uniformly a short-term outcome of a successful attempt at CPR, and 2) being “on machines” is often not a permanent “condition”. Once this is adequately explained to patients, they generally feel comfortable selecting CPR or no CPR in Part A.

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Q: What if a patient does not want to complete one of the sections?

A: That’s fine! Cross out section and write “No Decisions Made”– Doesn’t create false perception of patient wishes– Stops someone else from just checking a box in the future– Treat that section in the same way you would for any patient

who arrives without a form– Start a discussion with patient or legal representative

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Q: Is Section B of the form required? Some hospices are leaving the section blank. If section B is left blank is the form still valid?

A: If section A is completed, and section B or C are left blank – the POLST form is a valid order in regards to what a first responder should do if the patient has died.

If section B is blank, first responders will treat with all indicated medical treatment.

If the patient does not want to complete sections B and C, rather than leaving it blank, we suggest that a line be drawn through the sections and “no instructions” be written.

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Q: If a person does not have a POAHC, would it be possible to usethe Surrogacy Act Priority Order to determine who can sign the POLST?

A: Yes, Illinois law (Illinois Healthcare Surrogate Act) directs us to identify a substitute decision-maker for a patient who lacks decision capacity. We are directed to first look for an agent with POAHC. If there is no agent or POAHC and no other advance directive document that gives adequate instructions for patient wishes, we are then directed to refer to the Illinois Healthcare Surrogate Act hierarchy - starting at the top and moving down.

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Q: If a patient has completed a POLST form in the hospital and then transfers to a SNF, does the form need to be revised and signed by the attending physician in the SNF? Or can we honor the form from the hospital – given that the patient doesn’t want to make any changes?

A: Any POLST form that has been appropriately completed needs to be recognized in any medical setting.

We have seen situations where a patient is transferred with a POLST form, but a different receiving physician is not aware of the existence of the form. One way to reinforce awareness of the POLST order could be to have the receiving attending physician complete another form (and, in doing so, confirm the discussion and wishes by speaking with the patient and family). In any case, every institution must have a way to communicate to all staff when there is a valid POLST form in place, no matter who has signed the order, so that the patient’s wishes will be honored in an emergency.

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Q: Is there an official color that should be used for the POLST form?

A: The POLST form is valid on any color paper. A brightly colored form is recommended, and bright pink is the standard color recommended across the country. The bright pink color copies well without creating black smudges.

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Q: Should a different color form be used for the form if a

person wants to be resuscitated?

A: Some nursing homes are addressing the potential for confusion about whether the form is representing a patient’s wish to have CPR or whether it is representing a patient’s wish not to have CPR by using different colored paper for each. If a patient wants to be DNR the nursing home copies the POLST form onto red paper, and when the patient wants to be full code, green paper.

We are not endorsing this practice, but we think it is a clever way to address this potential for confusion.

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Q: Can a nurse sign the physician’s signature on the form, as he/she would a verbal order, if the physician is not available?

A: Yes, if absolutely necessary. If it is necessary to take a verbal order, the physician should sign the form as soon as possible, according to institutional policy/procedure.

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Q: Who can sign the POLST form as a witness?

A: The law says anyone over the age of 18• IDPH website adds that witness “may include a family member,

friend or health care worker”

• Recommend avoiding appearance of conflict of interest– When possible, someone not directly involved in patient’s

care, like another nurse, social worker, family member, etc. however this is not required

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Q: If the patient is confused, and the POA lives out of town, is it acceptable to call the POA and sign it as you would a verbal order from a physician?A: Ideally, the goal is to complete a POLST form when the patient is still able to make decisions. This is not always possible, however. Whether a clinician can accept a verbal/phone consent from the appropriate decision- maker to a POLST order should be determined by each institution. Institutions can assess whether the practice would be the same for POLST as for other consent forms.

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Q: I recently received a POLST form in a hospital, and there was information missing including DOB, gender and address. Am I allowed to complete these sections of the current form, or do I need to complete a new form?A: This something you should check with the policy and procedure person at your hospital.

While I am not a lawyer, I would personally think it would be ok to add those items as long as you are confident you are dealing with the same patient. When a change has been made, initial the addition and maybe write a note in the medical record that you have made the change.

Ultimately, the decision is up to your institution.

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Q: Couldn’t the use of red/green paper increase the risk that the form won’t be read and that an error in color would lead to the wishes not being followed?

A: You could argue both sides of this point. This practice is determined by policy of individual institutions. Staff and first responder education is critical in any case. The specific orders on the form must be reviewed, rather than making

assumptions.

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Q: Who can authorize the reversal of the POLST orders?

A: The patient, when decisional, or the appropriate substitute decision-maker/legal representative can revoke previous POLST orders.

Physicians and other practitioners may not reverse the POLST orders unless authorized by the appropriate decision-maker.

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Reversal of POLST Orders

Extreme care should be taken when a substitute decision-maker wishes to reverse the direction of care previously established by the patient, particularly if the patient had selected a treatment plan that focused on comfort care.

A legal representative may make new decisions, but generally should not be permitted to overturn decisions already made by the patient ,unless there is evidence that the patient had faulty information, misunderstood the information given, or would have changed decisions based on current developments in his or her medical condition.

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POLL:How confident are you that staff in your facility are able to interpret a

patient’s completed POLST form inthe setting of a medical emergency?

Answers:CompletelySomewhatSlightlyNot at allDoes not apply

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A: A time-honored practice has been to signal critical patient information (e.g., allergies, code status, etc.) by placing stickers on the fronts of paper charts.

The more information included on a sticker, the more chance there is for human error in transferring information from the form. The POLST form is complex, and is used to reflect patient wishes following a detailed conversation. There is a risk of information being lost when “shorthand summaries” could replace review of the actual form, especially in an emergency.

Each institution should assess their own level of staff understanding/education to determine policy/procedure regarding this issue.

Q: Should organizations use stickers on a patient’s chart to indicate POLST orders?

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Q: In a skilled nursing facility, should the POLST form be signed by each resident’s PCP or our medical director?

A: This is my personal opinion, but I believe it depends on who would be contacted in the case of an emergency. If the practice is to call the patient’s primary care physician when there is a medical deterioration, it would make sense that this physician is the one involved in the conversations who then signs the form.

It is critical that there is communication with any treating physician about the existence of the form for a patient who is deteriorating, to ensure the instructions on the form are followed. The physician communicating with the first responder needs to be aware of the instructions.

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• For more information on the National POLST program, visit www.polst.org.

• For Illinois-specific resources, visit www.POLSTil.org.

• Illinois POLST will be setting up Facebook and Twitter accounts in the near future.

For Updates and Current Information

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Thank You

Dr. Julie Goldsteinpolstil.org

POLSTillinois@gmail.com

46This material was prepared by Telligen, the Medicare Quality Improvement Organization for Illinois, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. The contents presented to not necessarily reflect CMS policy. 10SoW-IL-GEN-04/14-709

Telligen’s Contact Info

• Meghan Foley – Project Assistant– Meghan.Foley@hcqis.org– 630-928-5805