What is POLST? Physician Orders for Life Sustaining Treatment

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 2 Why POLST? 1.Patient wishes often are not known. The Advance Health Care Directive (AHCD) may not be accessible, clear, or honored. 2.Allows healthcare professionals to know wishes for end-of-life care and honor them.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 3 Case Study: What We Know Mr. Jones, an 83 year old man with severe chronic obstructive pulmonary disease (COPD) and mild dementia. In skilled nursing facility (SNF) after hospital stay for pneumonia. Developed increased shortness of breath and decreased responsiveness. SNF called Emergency Medical System who transported patient to hospital.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 4 Case Study: What We Know Emergency Room physician could not find any code status information in SNF papers. Wrote “Full Code for now, status unclear.” Mr. Jones was intubated and transferred to the ICU.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 5 Case Study: What We Didn’t Know Mr. Jones had an AHCD. It was at his home so the SNF couldn’t send it to the hospital. Mr. Jones had talked with his family and SNF staff about his desire not to go back to the hospital and receive aggressive treatment. There was no documentation of the conversation to alert the ED staff. The weekend nurses at the SNF could not reach his family and did not know about his wishes.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 6 Case Study: What Went Wrong AHCD not transferred with patient. DNR wishes not documented. Over-treatment against patient wishes. Unnecessary pain and suffering. System-wide failure to document and honor patient wishes.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 7 What is POLST? A physician order recognized throughout the medical system. Portable document that transfers with the patient. Provides direction for a range of end-of-life medical treatments. Brightly colored, standardized form for entire state of CA.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 8 Who Needs POLST? Chronic, progressive illness Serious health condition Medically frail Tool for determination “You wouldn’t be surprised if this patient died within the next year.”

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 9 POLST History POLST development began in Oregon in Initially for SNF patients transferred from one care setting to another. Use of POLST now expanded to more than 23 states. Oregon study of 180 SNF patients – POLST stated: No CPR and Comfort Measures Only. Patient wishes were honored.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 11 POLST in California California Coalition for Compassionate Care (CCCC) is lead agency with support from California HealthCare Foundation CA Assembly Bill 3000 Effective January 1, 2009 One form for entire state Use not mandated Honoring form is mandated

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 12 Does POLST Replace the Advance Health Care Directive? POLST does not replace the Advance Health Care Directive (AHCD). AHCD allows you to name a health care decisionmaker if in the future you are unable to communicate wishes. Encourage everyone 18 years and older to complete an AHCD.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 13 Where Does POLST Fit In? Advance Care Planning Continuum Complete an Advance Directive Complete a POLST Form Age 18 End-of-Life Wishes Honored Diagnosed with Serious or Chronic, Progressive Illness (at any age) Update Advance Directive Periodically C O N V E R S A T I O N

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 14 POLST vs. Pre-Hospital DNR (Do Not Resuscitate) POLST and Pre-Hospital DNR: Physician orders Address Do Not Resuscitate Medically frail or those with chronic or serious illness POLST: Allows for choosing resuscitation Other life-sustaining treatments Honored across all healthcare settings Pre-Hospital DNR: Honored outside hospital only (home, assisted living, SNF, EMS system)

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 15 POLST vs. PIC (Preferred Intensity of Care) Both include choices for medical interventions PIC forms are not medical orders and do not transfer to other settings POLST can replace the PIC form at SNF

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 19 Section B: Medical Interventions CPR Full Treatment* DNR Comfort Measures Limited Treatment *Consider time/prognosis factors under “Full Treatment” “Not to be kept on life support if not expected to recover.”

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 25 Who Can Speak for the Patient Agent/surrogate decisionmaker Parent, guardian, conservator Closest available relative

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 26 When to Review POLST Patient’s treatment preferences change. Change in patient’s health condition. Transfer from one care setting to another. Patient Care Conference.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 27 Can POLST be Changed? Individual with capacity can change the POLST at any time. A health care decisionmaker may request a change to POLST based on a condition change or new information regarding patient wishes if patient lacks capacity. If care is medically ineffective or contrary to accepted health care standards.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 28 POLST: Depth of the Process POLST is not just a form. POLST facilitates rich conversations which integrate patients’ values and preferred preferences for treatment. POLST is not an Advance Directive, but part of POLST completion is encouraging completion of an AHCD. POLST incorporates the depth of comfort care which applies to everyone.

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 29 California POLST Project C alifornia The California Coalition for Compassionate Care (CCCC) provides leadership and oversight for POLST outreach activities in California, with support from the California HealthCare Foundation. C oalition for C ompassionate C are

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 30 POLST C onversation A rich conversation with each individual patient C omprehensive Education To promote excellent conversational skills with patients and families C onsistent Form Standardized form recognized across care settings Translating an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for medical treatment. C ommunity Collaboration Integrating POLST into the community standard of care California POLST Project

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 31 California POLST Form Available at Print on pulsar pink, 65# card stock paper Copies are acceptable Focus on the conversation

California POLST Education Program © May 2009 California Coalition for Compassionate Care Materials made possible by a grant from the California HealthCare Foundation 32 POLST Resources Provider and consumer brochures Frequently Asked Questions (FAQs) Guidebook for healthcare professionals Model policies and procedures Standardized educational curriculum Local POLST coalitions