1. 1 POST FORM How does this affect me?

2. 2 Tennessees Health Care Decision Act In 2004, the Health Care Decision Act was passed thus revising Tennessee law concerning health care decision making. In 2004, the Health Care Decision Act was passed thus revising Tennessee law concerning health care decision making.

3. 3 What does this act do? Protects patients right to make own health care decisions Protects patients right to make own health care decisions Promotes Advance Directives Promotes Advance Directives Reduces court involvement Reduces court involvement Defines legal protection for those who uphold Defines legal protection for those who uphold

4. 4 Types of Advance Directives Durable Power of Attorney for Health Care/Appointment of Health Care Agent Durable Power of Attorney for Health Care/Appointment of Health Care Agent Living Will/Advance Care Plan Living Will/Advance Care Plan POST form/ Universal DNR POST form/ Universal DNR

5. 5 How POST form came about? Tennessee needed one form to address DNR and other resuscitative services Tennessee needed one form to address DNR and other resuscitative services Tennessee needed one form utilized by all healthcare entities in the state i.e. EMS, Nursing Homes, Hospitals, etc. Tennessee needed one form utilized by all healthcare entities in the state i.e. EMS, Nursing Homes, Hospitals, etc. Tennessee needed a universal form which could travel and be recognized across state lines Tennessee needed a universal form which could travel and be recognized across state lines

6. 6 Purpose of POST To provide a mechanism to communicate patients preferences for end-of-life treatment across treatment settings To provide a mechanism to communicate patients preferences for end-of-life treatment across treatment settings To improve implementation of advance care planning To improve implementation of advance care planning

7. 7 Basis of POST Encourages discussion with patient and family or surrogate decision maker of key end-of-life care issues

8. 8 Impact of Tennessee Law Acknowledged Universal Do Not Resuscitate Order Acknowledged Universal Do Not Resuscitate Order Means a written order that applies regardless of the treatment setting and that is signed by the patients physician which states that in event the patient suffers cardiac or respiratory arrest, cardiopulmonary resuscitation should not be attempted. Means a written order that applies regardless of the treatment setting and that is signed by the patients physician which states that in event the patient suffers cardiac or respiratory arrest, cardiopulmonary resuscitation should not be attempted. The law also indicated the Board for Licensing Health Care Facilities shall promulgate rules and create forms regarding procedures for the withholding of resuscitative services from patients The law also indicated the Board for Licensing Health Care Facilities shall promulgate rules and create forms regarding procedures for the withholding of resuscitative services from patients T.C.A. 68-11-224 (e), (5) & (i), (1)

9. 9 What is POST? POST – Physician Orders for Scope of Treatment POST – Physician Orders for Scope of Treatment What purpose POST form serves What purpose POST form serves Standardized form containing orders by a physician who has personally examined a patient regarding that patients preferences for end of life care Standardized form containing orders by a physician who has personally examined a patient regarding that patients preferences for end of life care Complements, but does not replace Appointment of Health Care Agent &/or Living Will/Advance Care Plan Complements, but does not replace Appointment of Health Care Agent &/or Living Will/Advance Care Plan Effective immediately upon order written and when all requirements met Effective immediately upon order written and when all requirements met Requirements for valid POST: Requirements for valid POST: Patients name and signature ( Patient signature optional according to facility policy ) Patients name and signature ( Patient signature optional according to facility policy ) Orders Orders Physicians signature (MD/DO) Physicians signature (MD/DO) Basis for orders Basis for orders

10. 10 POST Form Description POST Form format POST Form format Top of Form Top of Form Explanation of form Explanation of form Any section of form not completed indicates full treatment for that section Any section of form not completed indicates full treatment for that section When need occurs, first follow orders, then contact physician When need occurs, first follow orders, then contact physician Patients Name/DOB Patients Name/DOB

11. 11 POST Description cont. POST Format cont. POST Format cont. CPR: Code or No Code? CPR: Code or No Code? Level of intervention (i.e. comfort measures, limited additional interventions, and full tx) Level of intervention (i.e. comfort measures, limited additional interventions, and full tx) Comfort care level stipulates: Not to be hospitalized unless comfort interventions in the present setting fail – as applicable to the facility patient/resident is located in Comfort care level stipulates: Not to be hospitalized unless comfort interventions in the present setting fail – as applicable to the facility patient/resident is located in Use or withholding of antibiotics, IV fluids, and feeding tubes Use or withholding of antibiotics, IV fluids, and feeding tubes

12. 12 POST Description cont. POST Format cont. POST Format cont. Check 1 box each section Check 1 box each section SECTION A: Code Status SECTION A: Code Status Resuscitate or … Resuscitate or … Do Not Attempt Resuscitate Do Not Attempt Resuscitate If neither is marked, patient is to be resuscitated

13. 13 POST Description cont. POST Format cont. POST Format cont. Section B: Section B: Medical Interventions Medical Interventions Comfort Interventions: Treat with dignity and respect. Keep clean, warm, dry. Use medication by any route, positioning, wound care & other measures to relieve pain/suffering. Use oxygen, suction, manual tx of airway obstruction as needed for comfort. Do not transfer to hospital for life sustaining tx. Transfer only if comfort needs cannot be met in current location. Comfort Interventions: Treat with dignity and respect. Keep clean, warm, dry. Use medication by any route, positioning, wound care & other measures to relieve pain/suffering. Use oxygen, suction, manual tx of airway obstruction as needed for comfort. Do not transfer to hospital for life sustaining tx. Transfer only if comfort needs cannot be met in current location. Limited additional Interventions: Includes care described above. Use medical tx, IV fluids and cardiac monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care. Limited additional Interventions: Includes care described above. Use medical tx, IV fluids and cardiac monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care.

14. 14 POST Description cont. POST Format cont. POST Format cont. Full TX: All above plus CPR, intubation, defibrillation Full TX: All above plus CPR, intubation, defibrillation Other instructions_______________ Other instructions_______________

15. 15 POST Description cont. POST Format cont. POST Format cont. Section C: Antibiotics Section C: Antibiotics Treatment for new medical conditions Treatment for new medical conditions No antibiotics No antibiotics Antibiotics Antibiotics Other instructions____________ Other instructions____________

16. 16 POST Description cont. POST Format cont. POST Format cont. Section D: Medically Administered Fluids & Nutrition Section D: Medically Administered Fluids & Nutrition No IV fluids No IV fluids IV fluids for a defined trial period IV fluids for a defined trial period IV fluids long term IV fluids long term No feeding tube No feeding tube Feeding tube for a defined trial period Feeding tube for a defined trial period Feeding tube long term Feeding tube long term Other instructions__________ Other instructions__________

17. 17 POST Description cont. POST Format cont. POST Format cont. Where does the Physician Sign? Where does the Physician Sign? Section E: Section E: By a physician who has examined the patient (Mandatory) By a physician who has examined the patient (Mandatory) Discussed with…. Discussed with…. Physicians printed Name/Phone # Physicians printed Name/Phone # Basis for Orders Basis for Orders Patients preferences Patients preferences Patients best interest (Patient lacks capacity or preferences unknown) Patients best interest (Patient lacks capacity or preferences unknown) Medical indications Medical indications Other (specify) Other (specify)

18. 18 POST Description cont. POST Format cont. POST Format cont. Required Signatures: Required Signatures: Patient/legal rep, surrogate ( Patients signature is optional according to facility policy ) Patient/legal rep, surrogate ( Patients signature is optional according to facility policy ) Person preparing form Person preparing form Title/phone number/date Title/phone number/date Back of Form: Back of Form: Directions for Health Care Professionals: Directions for Health Care Professionals: Completing POST Completing POST Using POST Using POST Reviewing POST Reviewing POST

19. 19 Who Can Fill Out POST Form? Physician Physician Social Worker – experienced in a health care setting Social Worker – experienced in a health care setting Nurse Nurse * MD signs regardless who completes and must discuss form and contents with patient/responsible party

20. 20 Need POST if has DNR Order? POST addresses more than just DNR - POST addresses more than just DNR -Addresses… Comfort level IVs/NutritionAntibiotics Documents what individual was involved in discussion Signature of pt, parent, or guardian or Health Care Agent

21. 21 POST is for… Seriously ill patients* Seriously ill patients* Terminally ill patients Terminally ill patients * chronic, progressive disease/s

22. 22 Is POST required on all patients? NO on admission NO on admission Voluntary Voluntary Specifically focuses on medical treatment patient does or does not want at end of life Specifically focuses on medical treatment patient does or does not want at end of life YES on transfer to another health care facility YES on transfer to another health care facility

23. 23 What if Patient already has Advance Directive? POST reinforces wishes expressed in advance directive POST reinforces wishes expressed in advance directive POST is a physicians order that should be immediately used to direct the care of the patient POST is a physicians order that should be immediately used to direct the care of the patient Recommend very ill patients have both, POST & Advance Directive Recommend very ill patients have both, POST & Advance Directive

24. 24 Need DNR order if have POST? POST serves as the DNR order POST serves as the DNR order

25. 25 When Should Form be Reviewed? When patient is transferred from one health care facility to another When patient is transferred from one health care facility to another Facility initiating transfer must communicate the existence of POST form to receiving facility PRIOR to transfer (POST form must accompany the patient to the receiving facility) Facility initiating transfer must communicate the existence of POST form to receiving facility PRIOR to transfer (POST form must accompany the patient to the receiving facility) POST orders remain in effect in receiving facility POST orders remain in effect in receiving facility After admission, attending MD should review & a healthcare professional should initial POST After admission, attending MD should review & a healthcare professional should initial POST If patients condition significantly changes, such as: If patients condition significantly changes, such as: Close to death Close to death Extraordinary suffering Extraordinary suffering Improved condition Improved condition Advanced progressive illness Advanced progressive illness Permanent unconsciousness Permanent unconsciousness When patients preferences change When patients preferences change

26. 26 Changing the POST Form Void the form; complete a new one Void the form; complete a new one How to Void the POST How to Void the POST Draw a line through the Physician Orders Draw a line through the Physician Orders Write the word VOID in large letters, then Write the word VOID in large letters, then Sign or initial the form Sign or initial the form After voiding the form, a new form may be completed – leave VOIDED form in permanent record After voiding the form, a new form may be completed – leave VOIDED form in permanent record If no new form is completed, full treatment & resuscitation may be provided If no new form is completed, full treatment & resuscitation may be provided

27. 27 Must Health Care Comply with POST Form? YES YES Providers can be disciplined by their licensing board for failure to honor advance directives or decisions of surrogate, provided provider had actual knowledge of directive Providers can be disciplined by their licensing board for failure to honor advance directives or decisions of surrogate, provided provider had actual knowledge of directive Law protects good faith compliance with honoring Advance Directives Law protects good faith compliance with honoring Advance Directives

28. 28 Why POST Works By law MUST accompany patient By law MUST accompany patient Contains specifics Contains specifics It IS a physicians order – no interpretation is needed and POST orders are to be followed It IS a physicians order – no interpretation is needed and POST orders are to be followed

29. 29 Take-Home Messages (about POST Form) POST provides a better means to identify and respect patients wishes POST provides a better means to identify and respect patients wishes POST completions will improve end-of-life care throughout the system POST completions will improve end-of-life care throughout the system Use of POST will require communication to make it work in your community Use of POST will require communication to make it work in your community Wheres the POST form? Wheres the POST form? www.tennessee.gov/health www.tennessee.gov/health www.tennessee.gov/health www.endoflifecaretn.org www.endoflifecaretn.org www.endoflifecaretn.org