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

Friendship Friendship Staff TrainingStaff Training

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An Index Case

Mr. Jan, a 71-year-old male with severe COPD 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 as a valid DDNR

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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 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 to be

followed

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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–POST orders are to be followed

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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

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.

POST Project Policy and Procedure

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POST Can Be Completed In Many Settings

Let’s Review

• True/False– If a patient has a living will they don’t need a POST

form.

Let’s Review

• False. A living will is a more generalized statement of wishes. A POST is physicians orders for specific care wishes of the resident and these orders must be followed

Let’s Review

• Which residents are candidates for completing a POST form?

Let’s Review

• A POST form is appropriate for residents who– Are terminally ill– Are seriously ill with a progressive, chronic disease– Are not expected to live more than a year

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.

Who is Participating in the Pilot?

• List your participating pilot project groups here

EMS Participants

• List your participating EMS and transport groups here

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.34

On the top of the transfer packet!

“Where is the POST form?”

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At Transfer

• The yellow POST form placed in a red envelope with a label and placed at top of transfer documents:– “POST Order Form---This Form is to Accompany

the Resident Upon Transfer or Discharge; if resident returns to (name of facility), please return this form to: (address of facility)

• EMS, hand this envelope to person in charge of receiving resident/patient transfer documents.

Let’s Review

• What color is the POST Form?• True/False: In order for a POST form to be

valid, it must be signed by an MD or DO licensed in Virginia

• True/False: EMS will not recognize the POST form as a valid DDNR

Let’s Review

• Section A of a resident’s POST form says he wishes to not be recussitated. Section B of a resident’s POST form indicates that the resident wants Comfort Measures. You find the resident unresponsive, has shallow respirations with long periods of apnea, and a pulse of 100. What should you do?

Let’s review

• As long as the resident’s comfort can be provided for at the facility, this resident is not to be transferred to the hospital.

• How would you handle it, if a family member were insisting that you send the resident to the hospital?

How to Complete a POST Form

• Must be completed by a health care professional who has been trained as a POST Advance Care Planning Facilitator (ACPF).

• Must be based on patient/resident preferences

• Must be signed by an MD or DO

Why an Advance Care Planning Facilitator (ACPF)?

Why an ACPF?• Has received training in having discussions

with patients and POA’s about preferences for EOL care

• Training was based on our POST form• The Advance Care Planning process takes

about 45 minutes and often involves follow-up and/or additional sessions

• It is important that POST form is not just a check off sheet---an ACPF can make sure people know and understand their options

Who are the Trained ACPF’s at Your Facility/Organization?

• List names of trained ACPF here

Steps to Starting POST ProcessFor the Resident

• List steps for your facility here

Upon Transfer/Discharge of a Resident with POST Form

List your facility’s procedure here• Prior to discharge/transfer to another care

setting, the resident’s nurse or social worker arranging the transfer will notify receiving facility by telephone call of POST form.

• Put original POST form into a labeled red envelope and place at top of transfer documents.

• Unit Support: Make sure a photocopy of the current POST form is in Advance Directives section of the resident’s chart

Envelope LabelORIGINAL

POST/DDNRForms Enclosed

Forms are to accompany Resident upon

Discharge/Transfer

PLEASE RETURN ORIGINAL FORM IN THIS ENVELOPE

TO:

Friendship Health and Rehab Center327 Hershberger Rd., NW

Roanoke, VA 24012

The Red Envelope for Transfer/Discharge

Let’s Review

• Where does the current original copy of the POST form go in the chart?

• Who may help a resident/POA complete a POST form?

• What do you do if a resident with a POST form is to be transferred to another health care setting or home with hospice care?

Let’s Review

• Upon transfer:– Review the steps for your facility

Communicate, Communicate, Communicate!

• Make sure receiving care setting knows there’s a POST form.

• Make sure the EMS or transport personnel know that there is a POST form and show them where it is.

• Ask EMS/transporter to point out POST form to person receiving the resident.

• When resident returns, ask “Where’s the POST Form?”!!!!!!

Resident Dies at Your Facility

• List your policy/procedure for filing of the original POST form in the resident’s medical record, if resident dies at your facility

Resident is Admitted with a POSTList your policy/procedure---see example below.

• Admissions: Notify receiving unit of POST• Unit Support: Place the original in the very

front of the resident’s chart in a clear plastic sleeve. Notify PCP and Palliative Care Team that there’s a POST form.

• PCP or ACPF: – Review the POST form with the resident; – Enter orders consistent with those in the POST

form.

Resident Admitted with POST

• If the resident wishes to change the POST form, the original POST form shall be voided, and a new one completed.

Revising/Voiding a POST FormList your policy/procedure---see example below

• If a POST form is rewritten or voided during the admission:– The PCP or ACPF shall void the non-current

version by drawing a line through Sections A through E and writing “VOID” in large letters.

– The voided POST form shall be placed in the Advance Directives section of the thinned chart.

– If appropriate, the attending physician or a Certified Advanced Care Planning Facilitator shall complete a new POST form

Who Does What?

• Let’s review.• See handout: POST Duties for your facility’s

staff

Everyone!(Whether Medical, Nursing, Social Services,

Admissions or MDS)

Keep your eyes and ears open to

residents who might need ACP and a POST form

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?