POLST: Pennsylvania Orders for Life-Sustaining Treatment

1. POLST:Pennsylvania Orders for Life-Sustaining Treatment Respecting Wishes Across Care Settings CME Program for Physicians, Mid Level Practitioners and Nurses May 2014

2. Objectives At the conclusion of this program, the health care worker will be able to: • Define POLST • Discuss the process for implementing POLST at St. Luke’s • Demonstrate understanding of SLUHN roles and expectations related to POLST

3. What is an Advance Directive? • Advance Directives allow individuals to document wishes concerning medical treatments at the end of life • Examples • Health Care Power of Attorney document • Living Will document • A written combination of a Health Care Power of Attorney document and a Living Will document • Allowing patients to retain control over the life-prolonging treatment they choose to receive requires advance planning

4. Barriers to Advance Care Planning Health Care Professional’s View: • Difficult conversation to have • It may be unclear how to start the conversation • It may raise issues that are difficult to resolve • Requires time for discussion Patient’s View: • Very personal • May elicit strong emotional reactions • Conflict about who would make decisions and how decisions can be made • Difficulty making decisions regarding when medical treatment should be continued or forgone System’s View: • Communication • Documents may not be available • Instructions in documents • May be too vague or too specific to be helpful • Not available when needed • Efforts to reopen the conversation are rarely made

5. Two Types of Advance Directives Traditional – • Little or no impact on immediate course of care • Living will • Durable Healthcare Power of Attorney Actionable – • Direct and relatively immediate impact on course of care • POLST Paradigm • Do not resuscitate order (DNR) • Out-of-Hospital DNR McAuley & Travis, Am J Hospice & Palliative Care 2003;20(5):353-359.

6. Advance Directives Pennsylvania recognizes two types of Advance Directives Living will – describes wishes regarding medical care if you cannot speak for yourself • Only applies to patients with an end-stage medical condition or are permanently unconscious and who are incompetent • “If-then” model when determining care Durable Power of Attorney for Healthcare – allows you to appoint a person to make healthcare decisions for you in case you cannot speak for yourself • More flexible than a living will • Does not list specific treatment wishes

7. POLST Pennsylvania (Physician) Orders (for) Life Sustaining Treatment Purpose: To communicate a summary of a patient’s preferences and provide medical orders for end-of-life treatment across care settings that is easy to interpret in an emergency situation.

8. About POLST • A medical order indicating a patient’s wishes regarding treatments commonly used in emergent situations • Also helpful in guiding treatment after the initial emergency • The POLST form complements the Advance Directive – it does not replace it • An advance directive is necessary to appoint a legal health care representative • Does not replace in-hospital DNR form - DNR form still needs to be completed

9. POLST is for… Seriously ill patients (chronic, progressive disease) Terminally ill patients Patients with advanced frailty Others interested in defining their care Unless it is the patient’s preference, use of the POLST form is not appropriate for persons with stable medical or functionality problems who have many years of life expectancy.

10. The Rationale for POLST:Limitations of Advance Directives • Advance Directive may not be readily available • Not completed by most adults • Not transferred with patient • May not have prompted needed discussion • May not be specific enough • No provision for care in the home/nursing home • May not address topics of most immediate need • May be overridden by a treating doctor • Does not immediately translate into a physician order

11. Comparison Advance Directive • For anyone 18 and older • Provides instructions for future treatment • Appoints a Health Care Representative • Does not guide Emergency medical Personnel • Guides inpatient treatment decisions when made available POLST • For persons with serious illness – at any age • Provides medical orders for current treatment • Guides actions by Emergency Medical Personnel when made available *exception in our region • Guides inpatient treatment decisions when made available

12. Comparison Advance Directive • Not always readily available • Statement of preferences may not be specific enough • Requires interpretation • No provision for treatment in the nursing home POLST • Stays with patient across care settings • Check boxes of preferences • Consistent terminology • A physician’s order to be followed across care settings POLST is designed to honor the freedom of persons with advanced illness or frailty to have or to limit treatment across settings of care

13. 5 Key P’s of a POLST Form • Physician(form may be completed by a physician, physician assistant with co-signing physician or certified nurse practitioner in PA) • Portable(travels with patient to any point of care to assure his/her wishes related to life sustaining treatment would not be lost in transition) • Preferences(turns patient’s treatment preferences and Advance Directives into medical orders) • Primary goal(to ensure wishes for treatment are honored) • PINK! (nationally accepted color…exception NJ form is GREEN)

14. Who can complete a POLST? In Pennsylvania… • Physician • Physician Assistant • Requires physician co-signature within 10 days • Certified Registered Nurse Practitioner • Individual assumes full responsibility for the medical indications of the orders and assuring they accurately reflect the person’s values • Also requires signature of patient or legal decision maker to make the form valid

15. The Heart of the Conversation • Frame discussion based on patient-centered goals for care (e.g. quantity vs. quality of life) • Voluntary, can change or revoke at any time • Comfort measures are always provided • Discussion should include likely contingencies for future medical treatment • Ensure sound informed medical decision-making • Conversation with Health Care Power of Attorney (HCPOA) and “family” as defined by patient • Completion of POLST form

16. Example Discussion Discussion should include likely contingencies for future medical treatment… Patient with advanced COPD • Is BiPAP acceptable? • Intubation/mechanical ventilation in ICU ok? • Feeding tube placement? • Long-term mechanical ventilation if patient cannot be weaned? • Would hospice or palliative care be preferred to above?

17. How to complete the POLST • If any section is left unchecked, the highest level of care must be provided Completed after discussion regarding treatment preferences with person or their health care agent/representative Any current advance directive should be reviewed

18. Part A: CPR • Applies only when patient has no pulse and is not breathing • Does not apply to any other medical circumstances • Ex. respiratory distress, irregular pulse, etc. • Would refer to sections B, C, and D • Two choices • Attempt resuscitation • Allow Natural Death (Consider/discuss out of hospital DNR) • Comfort Measures will always be provided

19. Part B: Medical Interventions • Applies to emergency medical circumstances for a person who has a pulse and is breathing • Three choices: • Full Treatment: All life-sustaining treatments are desired • Includes intubation/advanced airway, mechanical ventilation, cardioversion, critical care admit, etc. • May or may not need to be transferred to the hospital

20. Part B: Medical Interventions • Comfort Measures Only: desire those interventions that enhance comfort • Includes medications, positioning, wound care, oxygen, etc. • Limited Additional Interventions: includes comfort measures and medical treatment, and cardiac monitoring as indicated • Ex. Short term dehydration • Intubation/mechanical ventilation is not used • May transfer to hospital, but typically avoid critical care

21. Part C: Antibiotics • Stimulates consideration that antibiotics are life-sustaining treatment • Can help person clarify goals of care in the context of advanced serious illness • Three choices: • No antibiotics. Use other measures to relieve symptoms • Determine use or limitation of antibiotics if administration will improve comfort • Use antibiotics if life can be prolonged

22. Part D: Artificially Administered Hydration/Nutrition For person who cannot take food or fluids by mouth PA law presumes in favor of a patient wanting artificial hydration and nutrition unless individual expressed otherwise or there is clear evidence of such Oral fluids and nutrition must always be offered if medically feasible

23. Part D: Artificially Administered Hydration/Nutrition • Three choices: • No hydration and artificial nutrition by tube • Trial period of artificial hydration and nutrition by tube • Allows time to determine course of illness or opportunity to clarify goals • Long-term artificial hydration and nutrition by tube

24. Part E: Reason for Orders and Signatures Whom orders were discussed with Include additional information supporting the basis for the orders in the Patient Goals/Medical Condition box Signature of provider Date the form Patient/representative signature

25. Reverse Side of the POLST • Other contact section • Includes patient/representative and provider names and phone numbers if clarification of orders is necessary • Directions for Healthcare Professionals

26. Roles and Expectations The next slides provide an overview of the roles of St. Luke’s care providers using flow charts and a series of check points to determine your understanding. Review the processes and responsibilities assigned to each role. If a patient is seriously ill, terminally ill, or with advanced frailty, POLST should be discussed with the patient.

27. A Patient presents to the ED or is a Direct Admit and already has a POLST form…

28. Check Point #1 Q: A patient arrives at St. Luke’s with a POLST form. The physician who signed the POLST form is on staff. What happens next? A: The UC/RN makes a copy of the POLST for the chart and the physician acknowledges the presence of the POLST in HEC or progress notes.

29. Check Point #2 Q: A patient arrives at St. Luke’s with a POLST form. The physician who signed the POLST form is NOT on staff. What happens next? A: The UC/RN verifies whether the physician is licensed in Pennsylvania and makes a copy of the license verification for the chart. POLST may only be honored if the physician is licensed in Pennsylvania.

30. Unit Clerk Role

31. Check Point #3 Q: When a patient who has a POLST form is admitted, what happens next? A: The UC/RN places a copy of the POLST form and physician PA license verification under the Advance Directives Tab on the chart. The Original pink POLST form is placed under the Discharge tab of the patient’s chart and the RN is notified of the presence of the POLST.

32. RN Role

33. Check Point #4 Q: When notified that the patient has a POLST form, what does the RN need to do? A: The RN needs to: • Place notation on the SBAR • Notify the Case Manager during care coordination rounds

34. Check Point #5 Q: Upon patient discharge, what happens to the POLST form? A: The RN ensures the patient’s original POLST form goes with the patient on discharge…it is the patient’s property! A copy is maintained on the chart. The RN also ensures communication to the next provider of care as appropriate.

35. Physician Role

36. Check Point #6 Q: Who can complete a POLST form in Pennsylvania? A: In Pennsylvania, a physician, physician assistant (requires physician co-signature within 10 days or less) or certified registered nurse practitioner must sign the form assuming full responsibility for the medical indications of the orders and assuring that they accurately reflect the person’s values.

37. Goals of FY 2015 Highmark Quality Blue Hospital Pay for Value ProgramAdvanced Care Planning POLST implementation to communicate patient’s end-of-life preferences across continuum of care For patients ≥ 18 years old discharged from a hospital to a skilled nursing or long term care facility Target: POLST completion for at least 10% of this patient population (measured through claims data) Providers may consider using prolonged visit timing codes for Evaluation and Management Claims Anticipate expansion of this measure to outpatient offices for FY 2016 Other area hospitals are participating in this initiative

38. POLST Web Site Resources http://www.aging.pitt.edu/professionals/resources-polst.htm

39. References Author (2011). Advance Directives. #21 Administrative Policy and Procedure. Bethlehem, PA. St. Luke’s University Health Network. Black, J. S. (2010). Physician Orders for Life-Sustaining TreatmentRespecting Wishes Across Care Settings. Presentation on February 3, 2010 for St. Luke’s Hospital & Health Network. Tuohey, J. F. and Hodges, M. O. (2011). End of Life: POLST reflects patient wishes, clinical reality. Health Progress. (2011); March-April: 60-64. POLST physician orders for life-sustaining treatment paradigm (2014), from http://www.polst.org

40. Thank you! • You have completed the POLST educational program and are eligible to receive…