Materials adapted and used with permission from the Coalition for Compassionate Care of California, 1 The POLST Conversation Modified 1_12_2015

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 2 POLST Conversations  Developing skill and comfort with the POLST conversation.  Promote informed decision-making for patients/families.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 3 POLST Conversations  POLST conversations take place: – In doctor’s office. – During family meetings at hospital. – Upon admission to skilled nursing facility (SNF) and potentially other times during course of care. – At home with hospice or home health.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 4 Tools for POLST Conversations  POLST Script and Cue Card  Diagram of POLST Medical Interventions  POLST Conversation Points: Key Information  8-Step POLST Protocol  Demonstration of a POLST Conversation  Cultural and Spiritual Awareness

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 5 POLST Script – Conversation Introduction Prepare for the discussion:* – Review what is known about patient and family goals and values – Understand the medical facts about the patient’s medical condition and prognosis – Review what is known about the patient’s capacity to consent – Retrieve and review completed Advance Directives and prior DNR documents – Determine who key family members are, and (if the patient does not have the capacity), see if there is an identified health care agent, guardian or health care representative – Find uninterrupted time for the discussion *Adapted from the 8-Step POLST Protocol, developed by Patricia Bomba, MD, for the MOLST Program of New York State. Program information is found at:

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 6 POLST Script  Introducing the Conversation – To acquaint yourself with patient/family. – To evaluate patient understanding of his/her health condition.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 7 POLST Script – Conversation Introduction  Normalize the conversation: – We talk about this with everyone. – We want to know what you would want if you got sick again.  If questions remain: – Your doctor will talk with you.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 8 POLST Script – Section A  Use an easily understood medical situation. – Begin Section A by saying, “Pretend you had a heart attack… you have died a natural death.”

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 9 POLST Script – Section A  Clarify what CPR means and realistic outcomes.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 10 POLST Script – Section B  If “YES, try CPR,” then mark Full Treatment on Section B. – CPR requires Full Treatment, including ventilator.  Explore patient’s wish for continued aggressive medical interventions, if they were not getting better.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 11 Diagram of Medical Interventions *Consider time/prognosis factors under “Full Treatment”. “Defined trial period. Do not keep on prolonged life support.” 11 CPR Full Treatment* DNR Comfort Measures Limited Interventions

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 12 POLST Script – Section B  For “Do Not Attempt CPR,” introduce Section B with the medical situation, “If sometime in the future, you developed a bad pneumonia…”

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 13 POLST Script – Medical Interventions if “No Ventilator”  Some people want to go to the hospital for evaluation and treatment.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 14 POLST Script – Medical Interventions if “No Ventilator”  Other people who have advanced illness that cannot be cured, choose to have care focused on comfort.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 15 POLST Script – Limited Interventions for SNF Residents  Some choose to go to the hospital for treatment.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 16 POLST Script – Limited Interventions for SNF Residents  Others choose to be treated at the SNF where they live.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 17 POLST Script – Section C Section C “Antibiotics” requires a conversation on how they may be used to treat specific conditions. POLST form choices are: – No antibiotics. Use other measures to relieve symptoms; – Determine use or limitation of antibiotics when infection occurs, with comfort as goal; – Use if life can be prolonged. Since antibiotics may be useful in providing comfort in some situations, some patients prefer to wait and determine antibiotic use when an infection occurs.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 18 POLST Script – Section D  Introduce Section D with another medical situation saying, “There is one other case to talk about. If you had a stroke…”  Other medical conditions, such as advanced Parkinson’s and Alzheimer’s, can affect swallowing too.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 19 POLST Script – Section D  If you have trouble swallowing, we can change food texture and hand feed you.  Another alternative is Artificial Nutrition with medically prescribed formula.  It is important to clarify the benefits and burdens of medically-prescribed artificial nutrition.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 20 POLST Script – Section D  If you have trouble swallowing, we can change food texture and hand feed you.  Another alternative is Artificial Nutrition with medically prescribed formula.  It is important to clarify the benefits and burdens of medically-prescribed artificial nutrition.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 21 POLST Script – Section D  If you have trouble swallowing, we can change food texture and hand feed you.  Another alternative is Artificial Nutrition with medically prescribed formula.  It is important to clarify the benefits and burdens of medically-prescribed artificial nutrition.  Allow patient to determine his/her choice based on adequate information, his/her values and what is most meaningful based on condition and prognosis.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 22 POLST Script – Section E  Review obtaining signatures. – Documenting the POLST conversation if via the telephone. – Reinforce importance of talking to loved ones.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 23 POLST Conversation Points Key Information  Adds depth to POLST conversations  Helps answer frequently asked questions

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 24 Demonstration of a POLST Conversation  A straight-forward conversation to build comfort with the flow of the POLST Conversation.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 25 Cultural and Spiritual Awareness  Brief overview with key questions.  Cultural and spiritual awareness is vital during POLST conversations.