1. POLST: How Can We Do Better in Hospice?
Pam Hiransomboon-Vogel DNP FNP-BC ACHPN
Quality Improvement Committee Oregon POLST Program
I am excited to be here to talk to all of you about POLST. POLST is probably the most powerful clinical tool/ piece of paper.
I had the honor to serve as the chair of Oregon POLST QI committee, revised 2018 version. #12.
I am honored to be sharing these updates with you.

2. Objectives: Identify recent changes to the 2018 POLST form.
Discuss the POLST verbal order process.
Discuss the process used in their Palliative Care or Hospice program for completing the POLST form and for submitting it to the Oregon POLST Registry. 
Identify several strategies for avoiding the “7 Deadly Sins” in the use of the POLST form.  
POLST is more than a piece of paper. I want you to think about POLST as a clinical tool and how to position your POLST process to help your patients meet their goals of care.

3. What is POLST? www.oregonpolst.org
EOL movement started in Oregon most states have some sort of program. not all have registry.
medical cover sheet
version #12, going on 13

4. General Agreement: Patients (particularly those nearing the end of life) have the right to decline treatments they do not want and receiving those they do.
-Who is POLST for?
POLST is for individuals with advanced age or a serious illness such as advanced heart disease or cancer that has spread. POLST orders give you more control over the types of treatment you do or don’t want in a medical crisis.
If you decide that you don’t want to go back to the hospital, POLST gives you the opportunity to express that. If you decide that you want every treatment option in the event of an emergency, POLST gives you the opportunity to express that.

5. How Does POLST Work?
Conversations between patient and/or family members and health care professional
Diagnosis
Prognosis
Available treatment options
Benefits and burdens of each
Patient goals of care, values
-POLST begins with conversation
-Ideally, the ACP conversations have been occurring for a while.
Prognosis- likely disease progression (ICU story)
Patient goals of care/values– how patient would like EOL care to look
Using all that information, the HCP and patient work together to make decisions about desired treatment. The HCP completes the POLST, documenting the decisions; the HCP signs the POLST.

6. How Does POLST Work? Health care professional completes & signs POLST.
POLST should never be given to patient to fill out on their own.
Original POLST is given to patient.
Put a copy in patient’s medical record.
Send a copy to Registry unless patient opted out.
Health care professional completes & signs POLST.
-Confirm required fields are complete and legible:
-Full name - Provider Signature -Date of Birth - Date Signed
-At least one order selection is completed* (example: In section B ‘Limited Intervention’ is checked)
*The Registry cannot accept forms marked Attempt CPR & Comfort Measures Only
-Inclusion of address information for the patient is HIGHLY recommend
Send a copy to Registry unless patient opted out.
-You may fax (Registry fax: ) or mail a copy of both sides of the POLST form.

7. POLST Registry
Facility submits form to the Registry (unless the patient opts out) Revisions/revocations to the POLST should be submitted to the Registry
how to revise
how to void/revoke

8. The Oregon POLST Registry
Immediate/24 hour access to a POLST form
Provides Registry ID magnet and stickers for patients
-began in 2008 in response to a need expressed by EMS to access POLST orders in emergent situations
-The Registry will send the patient a confirmation packet that includes a letter, Registry ID refrigerator magnet, and set of stickers for easy reference and display.
How does the Registry work?
» Completed POLST forms are submitted to the Registry
» Forms are reviewed for validity (see next section for required form elements)
» Forms are entered into a secure electronic database and checked for accuracy
» Once checked, form information is available for health care providers caring for patients
» Non‐urgent POLST form requests can be made through the Registry Business office, M‐F, 8‐4:30
» First responders or other emergency health care providers can call the Registry Hotline, located at the OHSU Emergency
Communications Center, when a paper POLST form cannot be located.
» Emergent requests (from first responders, Emergency Departments and ICUs) are handled by the Registry Hotline staff 24
hours/day, 7 days/week.
Registry: (toll free )

9. 2018 Oregon POLST Form www.oregonpolst.org
The 2018 POLST form went into effect on January 2, All prior versions remain valid. We ask facilities to throw away blank versions and replace with the new version because we are making improvements with each revision.
In the 2018 version, there are several important changes:
1 – Demographics: Per Medicare, remove SSN
2 – Demographics: Per Oregon DMV, Add third gender X non-binary
3 - A – CPR options side by side
4 - C - Artificially Administered Nutrition changed order to least aggressive
5 - F – Attestation: Per SB856, Add Naturopathic Physicians (ND)
6 - F – Attestation: Remove Office Use Only and add "Signed" means a physical signature, electronic signature or verbal order documented per standard medical practice. Refer to OAR

10. What changes will impact Hospices?
The Oregon POLST Registry—as of Oct. 13th, may now accept POLST forms signed by Verbal Order.
Hospice staff will no longer have to wait for a POLST form to come
back signed by a Provider before it can be FAXed to the POLST Registry.
This allows the current POLST form to be accessed by
EMS from the Registry much more quickly than in the past.
This will prevent unwanted treatments (e.g. from previous
POLST forms) from taking place.
did you know that you can always do verbal order with POLST? what is new is the ability for registry to accept verbal orders?

11. Logistics/Suggested Steps:
A Hospice staff person assists a patient to complete the POLST form.
A Verbal Order for POLST is obtained from the Attending Physician/NP or by the Hospice Physician/NP
The Hospice staff person documents the Verbal Order (“VORB” or “VO” or “TO”) with their name and role in the signature box, the date the order was authorized in the required Date field AND LEGIBLY prints the first and last name of the authorizing physician, with license number if possible, in the “Print Signing MD/DO/NP/PA/ND” row. This will allow easier and faster entry into the Registry.
The Hospice staff person then takes the POLST form and, using a FAX cover sheet, FAXes it to the Registry and returns the POLST form ASAP to the patient’s home.
Acceptance of POLST forms signed by Verbal Order into the Oregon POLST Registry

12. 2018 Oregon POLST Form

13. Signing in the field when the patient is Unstable (#2):
Following verbal orders protocols valid with EMS (valid in the registry)
Complete two versions, send one for MD, PA, DO, NP to sign, patient keeps one
Submit signed version to Oregon POLST Registry
The Oregon POLST Registry cannot accept phone orders

14. In matching death certificates with POLST forms, the Oregon POLST Registry found that over 10,000 patients enrolled in home hospice in Oregon between 2014 and 2016 did not have a POLST form in the Registry at the time of death.
now we are going to move on to talk about how hospice can improve the POLST process.

15. Why is this important for Hospice patients in Oregon?
After recently reviewing death certificate data and the Oregon POLST Registry, two key facts emerged:
Half of all of those who are enrolled in hospice do not have a POLST form in the Oregon POLST Registry at the time of death.
Of the half who do have a POLST form in the Registry, 1/3 have a POLST form with orders to be admitted to the hospital (either Limited or Full Treatment)-likely many of these forms are outdated but they are guiding emergency treatment in a crisis.
likely due to delayed signing or submission

16. How can Oregon Hospices ensure their patients’ wishes at the end of life are followed?
By facilitating same-day submission of a completed POLST form to the POLST Registry.
By returning the original POLST form to the patient’s home “ASAP”.

17. Use of POLST in Hospice
Resuscitation status alone does not predict level of treatment preferences
Approximately 20% of patients with DNR orders selected Limited Interventions
1 in 5 patients with DNR wanted more than CMO
not all hospice patients need to be CMO but what if patient and POLST form end up in acute care setting and how POLST form will be interpreted in non-hospice setting.
Susan E. Hickman, et al. Journal of Palliative Medicine.
February 2009, 12(2): doi: /jpm

18. Narrative

19. Issues with POLST in Hospice Delay in signing
Solution: verbal order at bedside and in registry, especially if patient/family at risk for activating EMS
Delay in faxing or failure to fax to the Registry
Solution: prompt submission to the Registry
Delay from receipt to entry to the Registry
Solution: signed POLST at bedside (verbal or wet signature)
Quality reports from Feb 2018
High volume of POLST submission to the Registry (5k a month, about 1k NRR)

20. What is your POLST process?
what I want you to think about
How long to signing
How long to faxing
Who does the submission
Low rate of POLST submission in hospice may result in unwanted medical treatments

21. www.oregonpolst.org Patient has a Signed POLST? YES NO
Patient has a
Signed POLST?
YES NO
Wishes/selections are current?
Fill out a new POLST
Signed within 2 years?
No need to sign a new POLST
At risk of activating EMS/go to ED and previously FULL code
Verbal orders for DNR/CMO obtained from MD/NP. Write VORB on signature line and date.
Leave original with the patient.
Fax a copy to Oregon POLST Registry (# on back of form) and bring a copy to office.
Bring POLST back to office. MD/NP sign within 1-2 business days.

22. POLST: outside of hospice

23. POLST-Avoid the seven deadly sins- Charlie Sabatino
Using POLST with people who are too healthy
Signing a POLST form without meaningful discussion
Having patients complete their own POLST form
Providing incentives for completing POLST forms
Failing to review POLST forms
Letting POLST disappear
Failing to evaluate your use of POLST paradigm
Charlie Sabatino-legal advisor to National POLST since At that time only six states had POLST Paradigm Programs: New York, Oregon, Pennsylvania, Washington, West Virginia and Wisconsin. Today, virtually every state (and Washington D.C.) has a POLST program under some stage of development and 22 of them have programs that meet the voluntary endorsement standards of the Task Force for programs and forms.

25. What is the impact of advance directives?
3 important thing they do:
They appoint a legally authorized surrogate. Default surrogate isn’t always the right person. They allow patients to outline their values in health care.
They lift an emotional burden. We have formally interviewed people 6 months after death of loved one, measured stress levels, people rated the stress (waking up at 2 am not knowing what loved one would want), family members have a lot of self doubt. Appointing a surrogate ahead of time prevents situations where family members have to make these decisions on their own.
POLST does not appoint HCR

26. POLST: When is the right time?
Show “POLST: When is the right time?”

27. Key differences between the Advance Directive and the POLST form

28. Who should have a POLST form?
One of the most common questions is “who should have a POLST form”? In Oregon, over 200,000 POLST Forms have been submitted to Registry in the 5 years it has been in operation. One of the challenges is that POLST is being offered to patients who are too healthy to have one. This is a problem because they are thinking about future not present health wishes. The POLST is for treatment wishes to be followed by EMS tonight if found down. Meaning that a 65 year old with no illness should have an advance directive, on a POLST form, this person would mark “yes” to everything. “Yes” to everything means that person shouldn’t have a POLST form because that is the treatment they would receive from EMS without a POLST form.
Offer POLST forms to persons who qualify as “I wouldn’t be surprised in the coming year due to advanced frailty (likewise, I wouldn’t be surprised if they lived another 2 years), clearly they are so frail that CPR would likely be unsuccessful.
There are some patients who are absolutely certain they do not want to go to the ICU and they want a POLST form (even though they might not be seriously ill or frail). This person after complete discussion with the Health Care provider should have a POLST.
Many patients in SNF for orthopedic procedures for example, do not meet this criteria and should not have a POLST

29. POLST is entirely voluntary
No one has to complete a POLST
Revoke or change at anytime
Comfort measures are always provided

30. While facilities routinely record Code Status, they cannot require that patients have a POLST form as a condition of care.
State and federal regulations do not require POLST forms for every resident of a long term care facility.
There is an urban legend that every patient in long term care needs to have a POLST mandated by the state. This is not true. The State does not require a POLST and the POLST cannot be required for care in a LTC facility. This legend is having people too healthy for a POLST fill them out and then they are living on in the registry. Only POLST appropriate patients should have a POLST.

31. Traditional code status orders
serve some residents
In case of cardiac arrest:
_____ Resuscitate
_____ Do Not Resuscitate
_______________________
Physician Signature
-for facilities that require medical orders, but patient is too healthy for a POLST form a code status document is a good alternative
60 y.o. in SNF for rehab after hip replacement

32. POLST should be offered to those with advanced illness or frailty.
Advanced Directive forms should be offered to patients without serious advanced illness.
POLST should be offered to those patients with advanced illness or frailty. Healthier patients should be encouraged to complete an advance directive.

33. This study looked at the association between POLST orders and in-hospital death. Most studies looking at Advance Directives show that whether you have one or not, you are equally likely to die in a hospital. AD’s don’t prevent in-hospital death. They enhance the opportunity to have the conversation, lift burden, shorten the time in hospital.
Advance Directives: appoint surrogate and lift a burden from family members
Extremely valuable, but they don’t change outcomes in where you die.

34. Oregon deaths in 2010 and 2011 with POLST forms in the Oregon POLST Registry: Nearly 18,000 (31% of deaths)
Looked at the first 2 years of Registry and matched death certificates with registry (31% of deaths in Oregon all counties represented).

35. How strong is the association between Section B POLST orders and location of death?
AD have no association with location of death- how strong is the association between orders selected on POLST form (section B) and location of death?

36. This chart explains why the IOM recommended that all states should adopt POLST. It shows the percent of people dying in the hospital. The first three bars are people with POLST Forms and what orders they chose in section B. The 4th bar is people who have no POLST form in the registry and where they die.
You see that there is a huge difference between the 11,836 people who marked CMO on their form and how only 6% of those died in the hospital.
44% of the group marking Full Treatment died in the hospital which is 10% higher than the group who had no POLST form at all.
POLST doesn’t keep you from getting treatment, it lines up with what you mark and the treatment you receive.
The 6% who marked CMO- about 1 time in 20 (or 5%) a patient’s comfort cannot be managed at home (broken leg, vomiting blood), and they need to be moved.
We are greatly reducing the instances where people receive care they do not wish to receive.

37. New POLST version 13 Removal of section C (artificial nutrition)
Allow room for further discussion
Some patients fill out POLST to refuse tube feeding
Changing the “P” from physician to portable to reflect function of the form and to be inclusive of non-physician signers of POLST
Voting in October 2018, likely roll out in early the version should be in place for 3-5 years.

38. Use of POLST educational materials in the field
All educational tools are available on the Oregon POLST website on the Resource Library Page
Videos
Brochures
PowerPoint presentations for health care professionals and the lay community
Guidebooks

39. Take home www.oregonpolst.org
think about how POLST help your patients meet their goals of care
1) prompt signing and submission
2) verbal order (0.3% of all POLST submission in 2018 so far)
3) using POLST appropriately

40. Questions?