POST. Physician Orders for Scope of Treatment 1 Respecting
Patients Wishes at the End of Life Brandon Oaks Brandon Oaks Staff
Training
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2 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 O 2 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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3 After EMS was unable to intubate him at the scene, they
inserted an oral airway, bagged, and transported the patient to the
emergency department (2 nd hospital). Mr. Jan remained
unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P
of 105, RR of 8, and an O 2 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.
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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 patients
wishes Unnecessary pain and suffering System-wide failure to
respect pts wishes Failure to plan ahead for contingencies No
system for transfer of plan 4
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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) or NP or PA allowed to sign under their practice
agreement. Complements, but does not replace, advance directives
Voluntary use Recognized by EMS as a valid DDNR 5
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POST is for Seriously ill patients* Terminally ill patients 6 *
chronic, progressive disease/s
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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 7
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Expected Outcomes of Using POST Process Improved continuity of
careForm 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.
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Conversations that change over time Source: Carol Wilson,
Riverside Health System; Used with permission Healthy Adults:
Emergency Planning People with Progressive Illness: guided planning
End Stage Illness: Physician Orders for Scope of Treatment
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Living Will* v. POST Living 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 physicians order to be
followed 10 *Fagerlin & Schneider. Enough: The Failure of the
Living Will. Hastings Center Report 2004;34:30-42.
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Why POST Works MUST accompany patient Contains specifics
Physicians orderno interpretation is needed POST orders are to be
followed 11
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Prompt for POST Completion 12 Would you be surprised if this
patient died in the next year?
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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
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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 14
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POST Can Be Completed In Many Settings
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Lets Review True/False If a patient has a living will they dont
need a POST form.
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Lets 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
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Lets Review Which residents are candidates for completing a
POST form?
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Lets 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
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Developing Programs National POLST Paradigm Programs Endorsed
Programs No Program (Contacts) *As of February 2013
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POST Pilot Project POST orders legally recognized in several
states, including West Virginia. Roanoke Valley is a POST Pilot
Project Region Plan to make POST a legal document recognized
throughout Virginia
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Who is Participating in the Pilot? Palliative Care Partnership
of the Roanoke Valley Friendship Health and Rehab Center Richfield
Recovery and Care Center Brandon Oaks Carilion Clinic: Roanoke
Memorial Hospital Lewis-Gale Medical Center (coming on board)
Hospice patients in the following hospices: Good Samaritan Hospice;
Carilion Clinic Hospice
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EMS Participants Roanoke County Fire & Rescue Roanoke City
Fire & EMS Salem Fire & EMS Local medical transport
companies Carilion Clinic Patient Transport Life Care United
Guardian Others
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POST Form
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The POST Form 25
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Section A: Resuscitation DNR orders only apply if a person has
no pulse and is not breathing Note: This section has 2 choices:
Attempt Resuscitation and Do Not Attempt Resuscitation: Check to
see which box is checked! POST Section A recognized as a valid
Virginia Other DNR. When Do Not Attempt Resuscitation is checked,
qualified healthcare personnel are authorized to honor this order
as if it were a Durable DNR order OEMS approval (Michael Berg)
27
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Section B: Medical Interventions If in the terminal phase, POST
and advance directive should be consistent Care plan should always
be consistent with POST If Comfort Measures are selected consider
hospice consultation 28
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Levels of Medical Interventions Comfort Measures Treat with
dignity and respect. Keep warm and dry. Use medication by any
route, positioning, wound care and other measures to relieve pain
and suffering. Use oxygen, suction and manual treatment of airway
obstruction as needed for comfort. Transfer to hospital only if
comfort needs cannot be met in current location. Also see Other
Instructions if indicated below. 29
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Levels of Medical Interventions Limited Additional
Interventions Include comfort measures. Do not use intubation or
mechanical ventilation. May consider less invasive airway support
(e.g., CPAP or BiPAP). Use additional medical treatment,
antibiotics, IV fluids and cardiac monitoring as indicated.
Hospital transfer if indicated. Avoid intensive care unit. Also see
Other Instructions if indicated below. Full Interventions In
addition to Comfort Measures above use intubation, mechanical
ventilation, cardioversion as indicated. Transfer to hospital if
indicated. Include intensive care unit. Also see Other Instructions
if indicated below. 30
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Section C: Artificial Nutrition These orders pertain to a
person who cannot take food by mouth Feeding tube for a defined
trial period: Gives option to determine benefit to patient and/or
recovery from stroke, etc. 31
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POST Sections (Other) Discussed with Physician Signature and
contact info Patient/Authorized Decision Maker Authority to sign
patient if patient is incapacitated Facility of POST form origin
Name and signature of Facilitator Instructions 32
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Original Form Shall Always Accompany Patient/Resident When
Transferred or Discharged! 33 On the top of the transfer
packet!
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Where is the POST form? 34
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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.
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Lets 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
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Lets Review Section A of a residents POST form says he wishes
to not be recussitated. Section B of a residents 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?
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Lets review As long as the residents 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?
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How to Complete a POST Form Must be completed by a physician or
by a non-physician 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; may be
signed by an NP or PA if within their practice agreement.
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Why an Advance Care Planning Facilitator (ACPF)?
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Why an ACPF? Has received training in having discussions with
patients and POAs 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
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Who are the Trained ACPFs at Brandon Oaks? Dr. Soheir Boshra,
MD Melissa Conner Kim Bain Jean Craddock Nancy Patterson
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Steps to Starting POST Process For the Resident Identify
residents who might be appropriate for POST process (due to
condition, resident/POA request, or else resident is admitted with
a POST form). Notify a POST ACPF that resident was admitted with a
POST form or resident might need a POST form completed
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Steps to POST Process Residents physician or ACPF completes
POST Form (or reviews POST form that came with resident upon
admission). If ACPF completes, then physician notified that there
is a POST form to sign.
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Steps to POST Process Person completing POST Form: Document in
Interdisciplinary Notes and Plan of Care Enter the orders into the
active medical record consistent with those in the POST order set.
Make copy of POST form to give to the social worker and to the
resident or their substitute decision maker. Original of POST form
goes in a clear plastic sleeve behind Advance Directives tag
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Steps to POST Process Person completing POST form (continued):
Place yellow POST sticker on the front of chart: Notify nursing
unit charge nurse and social worker that POST has been signed and
what those POST orders are Review POST form with resident/POA
periodically (at quarterly team meetings) and prn (i.e. when
condition changes)
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Transfer/Discharge Prior to discharge/transfer to another care
setting, the residents 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 Manger or Charge Nurse: Make
sure a photocopy of the current POST form is in Advance Directives
section of the residents chart
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Envelope Label ORIGINAL POST/DDNR Forms Enclosed Forms are to
accompany Resident upon Discharge/Transfer PLEASE RETURN ORIGINAL
FORM IN THIS ENVELOPE TO:
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The Red Envelope for Transfer/Discharge
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Lets 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?
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Lets Review Upon transfer: Call the receiving facility and
notify of POST Make sure a photocopy of POST form is in the Advance
Directives section of the chart Put original copy of POST form in
labeled red envelope and put on top of transfer packet Alert
EMS/transporter of the POST form
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Communicate, Communicate, Communicate! Make sure receiving care
setting knows theres 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 Wheres the POST
Form?!!!!!!
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Resident Dies at Brandon Oaks If the resident dies at Brandon
Oaks, the original POST form is to be placed in the Advance
Directives section of the closed medical record by Medical
Records.
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Resident is Admitted with a POST Admissions: Notify receiving
unit of POST Unit Support: Place the original in a clear plastic
sleeve in the Advance Care Planning section of the chart. Notify
PCP and POST Advance Care Planning Facilitator. PCP or ACPF: Review
the POST form with the resident; Enter orders consistent with those
in the POST form.
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Revoking/Making Changes to POST If the resident wishes to
change the POST form, the original POST form shall be voided, and a
new one completed.
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Revoking/Changing a POST Form To change POST, the current POST
form must be voided and a new POST form completed. If no new form
is completed, full treatment and resuscitation may be provided. As
long as the patient can make his/her own decisions, then the
patient can revoke consent for POST and also may request changes to
POST.
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Revoking/Making Changes to POST If a patient tells a healthcare
professional that he wishes to revoke his consent to POST or change
POST, the healthcare professional caring for the patient should
draw a line through the front of the form and write VOID in large
letters on the original, with the date and their signature, and
notify the patients physician. A new POST form then may be
completed if desired by the patient. The physician or a POST ACPF
may complete the new form.
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Revoking/Changing POST If Do Not Attempt Resuscitation is
checked in Section A and the patient has signed this form, no one
has the authority to revoke consent for the DDNR order other than
the patient as stated in the Code of Virginia section
54.1-2987.1.
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Revoking/Changing POST If the patient signs this form, then the
patients overall treatment goals should be honored if the patient
later becomes unable to make decisions. If the patient is unable to
make healthcare decisions, a legally authorized medical decision
maker, in consultation with the treating physician, may sign this
form, revoke consent to, or request changes to the POST orders
(except in section A as noted above) to continue carrying out the
patients own preferences in light of changes in the patients
condition.
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Revoking/Changing POST The voided POST form shall be placed in
the Advance Directives section of the thinned chart.
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Who Does What? Lets review.
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Questions?
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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
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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.
Wheres the POST form? 66