COLC Monthly Seminar 3 May 2012 Dr. Dan Kimball Ms. Elizabeth Moreli, ESQ. What is POLST and Why Should I Care?

What Most People Want at End-of-Life Respect my uniqueness as an individual Provide me with peace and comfort Address my spiritual needs Recognize my cultural heritage Communicate with me Help me with my pain (physical and emotional) Don’t prolong my dying Give me a sense of control Relieve the burden on my loved ones Touch

POLST What does POLST mean? P P - Physician (or Pennsylvania) O O - Orders for L L - Life S S - Sustaining T T - Treatment

History of POLST in PA Provider Task Force to Improve Care at the End-of-Life convened Pittsburgh End of Life Collaborative, a quality improvement initiative within fourteen nursing homes. Funded by Highmark, UPMC and the Jewish Healthcare Foundation Susan Tolle MD, of the Oregon Health Sciences University Department of Ethics and a leader in the launching of POLST, spoke to group of community leaders Coalition for Quality at the End of Life (CQEL) established 2006 – Passage of Act As mandated by Act 169, the Pennsylvania Department of Health Patient Life-Sustaining Wishes Committee convened October POLST approved by Pennsylvania Secretary of Health January Endorsed by the National POLST Paradigm Task Force 4

POLST So, What is a POLST form? A document that helps doctors, nurses, healthcare facilities and emergency personnel honor patient wishes regarding life-sustaining treatments in emergency situations. Goal is to improve the quality of care people receive at the end of life by turning Patient Goals and Preferences for care into Medical Orders.

HIPAA Compliant Cardiopulmonary clarifies type of resuscitation. Do Not Attempt Resuscitation assists clinicians in communicating odds about success Clear instruction on when to transfer to hospital and use of intensive care IV fluids in Limited Additional Interventions section Artificial hydration and artificial nutrition both found here Options give people the choice to decide later since issue of when to use antibiotics is complex Discussion about treatment preferences is required If any section left unmarked, the highest level of treatment must be provided PENNSYLVANIA FORM 6

. 7 PENNSYLVANIA FORM 2 ND SIDE

POLST More about POLST forms This is a voluntary process! For individuals with advanced chronic progressive illness and/or frailty! (I would not be surprised if this patient were to die within the next 12 months) For individuals who desire to further define their preferences for care in their present state of ill-health This is an extension of the Advance Directive Process for appropriate individuals

POLST What issues are included in POLST? Preferences related to Resuscitation Preferences for levels of Medical Care Preferences for the use of antibiotics Preferences for the use of artificial administration of fluids and/or nutrition (i.e., IV fluids and/or feeding tube)

POLST Who Completes the POLST Form? Physician, Nurse Practitioner, Physician Assistant can complete but must sign the form. Actual completion of the form may be done by other health professionals (i.e., nurses, social workers) Completed only after an appropriate discussion with the patient and/or surrogate decision maker. The document is also signed by the patient or the surrogate decision maker. It then becomes a “Medical Order” that can be understood and followed by other professionals.

POLST Where can POLST be used? Remains with patient in their setting (home, hospice, skilled nursing facility, long term care facility, personal care facility, or hospital). In facility, form kept on “medical chart” or record! At home, kept in prominent place (refrigerator, bedside table, or medicine cabinet). Travels with patient where ever they go! The bright pink color is to make the form obvious to any professional picking up the chart.

POLST A POLST form is not…. An Advance Directive (you can execute a POLST without a preceding Advance Directive) In conflict with the Advance Directive To take the place of a Health Care Agent To take the place of a Health Care Representative Required by any institution, law or regulation; it is completely voluntary

POLST Legal Requirements for POLST Form Must include the patient’s name. Section A (Resuscitation status) must be completed. Signature by Physician, CRNP or PA. Physician countersignature for CRNP and PA. Sections B, C and D are optional. Patient Signature preferred (institutional guidance).

Limitations of POLST completed by someone other than patient or Health Care Agent Neither a health care representative (as distinguished from a health care agent or health care power of attorney) nor a guardian of the person may decline care necessary to preserve life unless the patient is in an end-stage medical condition or is permanently unconscious.

POLST Suggestions for Periodic Review of POLST Yearly or semi-yearly (institutional guidance will control); at plan of care meetings, etc. With any significant change in health status With change in care setting or level of care With change in patient preferences for care At request of patient or patient surrogate decision maker Improved patient condition Advance worsening condition to permanent unconsciousness

Differences between POLST and Advance Directives 16 CharacteristicsPOLSTAdvance Directives PopulationFor the seriously illAll adults TimeframeCurrent careFuture care Who completes the formHealth Care ProfessionalsPatients Resulting formMedical Orders (POLST)Advance Directives Health Care Agent or Surrogate role Can engage in discussion if patient lacks capacity Cannot complete PortabilityProvider responsibilityPatient/family responsibility Periodic reviewProvider responsibilityPatient/family responsibility Bomba PA, Black J. The POLST: An improvement over traditional advance directives. Cleveland Clinic Journal of Medicine. In press.

Where Does POLST Fit In? Advance Care Planning Continuum Complete an Advance Directive Complete a POLST Form Age 18 Treatment Wishes Honored Diagnosed with Serious or Chronic, Progressive Illness (at any age) Update Advance Directive Periodically

Out-of-Hospital DNR EMS providers may only follow a PA OOH-DNR order, bracelet, or necklace 18

POLST Checklist for POLST Program Policy Development by all Healthcare Facilities For Advance Directives and POLST Process for Review of both and addressing conflicts To accept POLST orders from transferring facility Education Plan (Staff; Physicians; Patients) Notification of key contacts (EMS; Hospitals) Program Implementation (new pts; partial use; full use) Quality Improvement (Audits and feedback)

Selected Challenges Measuring the quality of the conversation underlying ACP and POLST. Training health care providers (Facilitators). Decision-making for those who have no appointed proxy. Educating health care agents/proxies. Evaluating protections for vulnerable population. 20

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POLST Website Resources nals/resources.htm Aging Institute of UPMC Senior Services and the University of Pittsburgh Center for Ethics in Health Care Oregon Health & Science University AARP Public Policy Institute