POST…. Physician Orders for Scope of Treatment

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Respecting Patients’ Wishes Respecting Patients’ Wishes at the End of Lifeat the End of Life

Objectives

• Describe the POST form and process• Explain the POST pilot project in the Roanoke

Valley

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An Index Case

Mr. Jan, a 71-year-old male with severe COPD, ESRD and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing SOB and decreasing LOC over 24 hours. The nursing facility staff called EMS who found the patient unresponsive, with a RR of 8 and an O2 sat at 85% on room air. Although Mr. Jan had discussed his desire to forgo aggressive, life-sustaining measures with his family and nursing personnel, the nursing facility staff did not document his preferences, inform the emergency team about them, or mention his do-not-resuscitate order.

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After EMS was unable to intubate him at the scene, they inserted an oral airway, bagged, and transported the patient to the emergency department (2nd hospital). Mr. Jan remained unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P of 105 , RR of 8, and an O2 sat of 88% despite supplemental oxygen. He had diminished breath sounds without wheezes, and a chest X-ray showed large lung volumes without consolidation. Arterial blood gases showed marked respiratory acidosis. The emergency department physician wrote, “full code for now, status unclear.” The staff intubated and sedated Mr. Jan and transferred him to the intensive care unit.

Lynn, et al. Ann Intern Med 2003;138:812-818.

What went wrong?(Could this happen in Roanoke?)

• Advance directives not documented• DNR order not communicated in transfer• Fragmentation in care (2 hospitals)• Overtreatment against patient’s wishes• Unnecessary pain and suffering• System-wide failure to respect pt’s wishes

– Failure to plan ahead for contingencies– No system for transfer of plan

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What is POST?• A physician order• Can be completed by a non-physician

provider but must be signed by qualified MD or DO (Osteopath)

• Complements, but does not replace, advance directives

• Voluntary use• Recognized by EMS and participating

facilities as a valid DDNR6

POST is for…

Seriously ill patients*Terminally ill patients

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* chronic, progressive disease/s

Purpose of POST• To provide a mechanism to communicate

patients’ preferences for end-of-life treatment across treatment settings

• To improve implementation of advance care planning

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Expected Outcomes of Using POST Process

• Improved continuity of care—Form will be transferable across treatment settings

• Clearer communication of wishes• Reduced hospitalization and inappropriate

life-sustaining treatments– Fewer EMS transports

• More accurate representation of preferences

• Higher adherence to wishes by medical professionals.

Living Will* v. POSTLiving Will

• For every adult• Requires decisions about

myriad of future treatments• Clear statement of

preferences• Needs to be retrieved• Requires interpretation

POST• For the seriously ill• Decisions among presented

options• Checking of preferred boxes

• Stays with the patient• A physician’s order

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*Fagerlin & Schneider. Enough: The Failure of the Living Will.Hastings Center Report 2004;34:30-42.

Why POST Works…

• MUST accompany patient• Contains specifics• Physician’s order—no interpretation

is needed–Participating facilities/agencies have

agreed to accept POST order sheet

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Prompt for POST Completion

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Would you be surprised if this patient died in the next year?

POST: Who Should Have One?

• Anyone choosing “Do Not Resuscitate”• Anyone choosing to limit medical

interventions• Anyone eligible/residing in a LTC facility• Anyone who might die within the next year

Patients on Dialysis

• Which patients receiving dialysis might benefit from an advance care planning session and a POST form?

Communication across Settings

The health care facility initiating the transfer shall communicate the existence of the POST form to the receiving facility prior to the transfer. The POST form shall accompany the person to the receiving facility and shall remain in effect in participating facilities.*POST Project Policy and Procedure*Note: Non-participating facilities will receive a letter with a patient’s completed POST form, explaining the form and encouraging receiving physician to review POST orders and use as guide in writing orders for the patient.

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POST Can Be Completed In Many Settings

POLST is Spreading

California, Georgia, Kansas,

Missouri, New Mexico,

Utah, Virginia,

Washington, West

Virginia, Wisconsin, New

York, North Carolina,

Maryland, Pennsylvania

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POST Pilot Project• POST orders legally recognized in

several states, including West Virginia.

• 8 regions in the state are conducting POST pilot projects over the next 2 years.

• Plan to make POST a uniform document recognized throughout Virginia.

It’s Not Just About the Form

POST Process

“ The problem with communication is the illusion that it has been accomplished.”

- George Bernard Shaw

The Conversation

• POST discussions must be facilitated by the patient’s physician or a trained Advance Care Planning Facilitator (ACPF). The facilitator may choose to involve other members of the patient’s healthcare team as well.

• The dialogue may or may not result in the completion of a POST document, but it does create an environment of shared and informed decision making for the patient facing serious illness.

Role of the ACP Facilitator (cont.)

• Explores patient’s understanding of CPR, comfort care, antibiotics, artificial nutrition and hydration, etc.

• Ensures that patient’s wishes are clearly documented on transferable form.

• Develops list of pertinent questions that may involve physician and others.

Role of the Advance Care Planning Facilitator (ACPF).

• Explores patient’s understanding of advance care planning and the role of a healthcare representative.

• Explores understanding of medical condition, including possible complications that may occur.

• Provides meaningful context for decision making through identifying previous key healthcare experiences, fears & worries, values, and important beliefs.

POST Form

Section A: Resuscitation

• Only section applicable to EMS• DNR orders only apply if a person is pulseless and apneic• POST recognized as a valid Virginia DDNR – OEMS approval (Michael Berg)

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Section B

• Review care plan to be sure that palliative care measures available• Institute palliative care measures as needed• If meets admission criteria consider hospice

Section B: Level of Medical Interventions

• Limited Additional Measures– Includes comfort care

described in previous section. However, may also use medical treatment, IV fluids, and cardiac monitoring as indicated.

– Do not use intubation, advanced airway interventions, or mechanical ventilation.

– Transfer to hospital, if indicated. Avoid intensive care.

• Full Treatment

– Includes care described in 2 previous sections.

– Use intubation, advanced airway interventions, mechanical ventilation, and cardiac defibrillation, as indicated.

– Transfer to hospital, if indicated. Include intensive care, if indicated.

Section B: Level of Medical Interventions

• Comfort Measures– Treat with dignity and

respect. Keep clean, warm, and dry.

– Use medication by any route, positioning, wound care and other measures to relieve pain.

– Do not transfer to the hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location.

Section C: Antibiotics

Example of “Other Instructions”: Antibiotics may be used only as needed for comfort.

(E.g., patients susceptible to UTI’s may reserve right to be treated with antibiotic for pain and discomfort.)

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Section D: Artificial Nutrition/Hydration

• These orders pertain to a person who cannot take fluids and food by mouth.

• IV Fluids or Feeding Tube for Defined Trial Period:– Gives option of trying either of these to determine benefit to patient

and/or for recovery from stroke or hydration from vomiting, etc.– Recommended trial for IV fluids = 2 to 7 days– Recommended trial for Feeding Tube = 30 days or less

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Section E: Participants & Physician Signature

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Section F: POST Reviews & Instructions

• Related EOL documents, if any, e.g., Living Will

• Signature of Patient or Legal Representative

• Signature of ACP Facilitator

• Directions for Health Care Professionals

POST Form Shall Always Accompany Patient/Resident When Transferred or

Discharged!*

* Note: Preferable to transfer with original current copy, but legible copies are to be honored as though

they are the original.35

On the top of the transfer packet!

“Where is the POST form?”

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Revising/Revoking a POST Form

• The POST form is recognized under the Health Care Decisions Act as a legal and binding advance directive and Durable Do Not Resuscitate order.

• EMS will honor the form as a DDNR.• Consider the following sections of the Virginia

Health Care Decisions Act:

Virginia Health Care Decisions Act

• Who may revise/revoke an Advance Directive:– “An advance directive may be revoked at any time

by the declarant who is capable of understanding the nature and consequences of his actions (i) by a signed, dated writing; (ii) by physical cancellation or destruction of the advance directive by the declarant or another in his presence and at his direction; or (iii) by oral expression of intent to revoke.”

– Note: There is no provision for anyone other than the declarant to change an advance directive

Virginia Health Care Decisions Act

• Who may revise/revoke a DDNR:1.“. . . In no case shall any person other than the

patient have authority to revoke a Durable Do Not Resuscitate Order executed upon the request of and with the consent of the patient himself.”

What does these mean for POST Form Revision?

• If the POST form was signed by the patient, then only the patient can revoke or modify the form and request alternative treatment.

• If the POST form was signed by a person authorized to sign on the patient's behalf because the patient lacked capacity to make medical decisions, then the authorized person can revoke or modify the form and request alternative treatment as long as the patient lacks decision-making capacity.

• Voiding or modifications of the form may be made verbally or in writing, and by marking through or otherwise obliterating the form.

Where do You Go From Here?

Take-Home Messages

• POST provides a better means than AD to identify and respect patients’ wishes

• POST completion will improve end-of-life care throughout the system

• Use of POST will require communication to make it work in your community

• Know your role.• “Where’s the POST form?”

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Questions?

Contact Information

• Laura Pole, RN, MSN, OCNS: POST Pilot Project Coordinator– Lpchef@earthlink.net – 540-529-5395

• Karen Mayhew, LCSW; Director of Patient Services, Good Samaritan Hospice– 540-776-0198