Physician Orders for Life-Sustaining Treatment (POLST): A National and Statewide Initiative

1. Physician Orders for Life-Sustaining Treatment (POLST): A National and Statewide Initiative 4th Annual Palliative Care Conference June 15, 2010 Elizabeth Balsam Hart, MD David F. Giansiracusa, MD Ross Wadland, MD

2. Acknowledgements • We have no financial relationships to disclose • Our appreciation to the National POLST Paradigm Initiative Task Force for generously sharing their expertise and allowing adaptation of their slides and to Respecting Choices, Gunderson Lutheran Medical Foundation, for their educational material.

3. Objectives • Know the essential components of an advance care planning program. • Know what Advance Directives (AD) are and appreciate their limitations. • Understand and appreciate the difference between Advance Directives and Physician Orders for Life-Sustaining Treatment (POLST) • Understand how the POLST program will improve communication and documentation of patients’ wishes

4. How Americans Die

5. Critically Important Care At End of Life: Care Which • Optimizes physical comfort • Maintains a sense of continuity with one’s self • Maintains and enhances relationships • Makes meaning of one’s life and death • Helps a patient achieve a sense of control • Helps the patient and family confront and prepare for death (Block JAMA 2001)

6. Ideally, patients would: • Be well-informed about their conditions and options for care • Appreciate and understand the benefits and burdens of the options for care • Express their wishes and preferences for care based on their goals, values, beliefs, and sense of quality of life • Have those wishes known and acted upon by health care professions wherever the patients may be.

7. Advance Care Planning (ACP):Definition • A process of planning for future medical decisions. To be effective, the person doing the planning needs to: -understand selected possible future situations and choices; -reason and reflect about what is best; and -discuss these choices and plans with those who might need to execute plan (Hammes B, Brasic G, Gunderson Lutheran Health System, La Crosse, WI. “Planning for Future Medical Treatment: What Worked….What’s Failed” (406), 2010 AAHPM & HPNA Annual Assembly, Boston, Massuchusetts)

8. Desired Outcomes: Advance Care Planning • Know and honor a patient’s informed plans by: 1) selecting and preparing a health care agent 2) creating specific instructions that reflect informed decisions consistent with a person’s condition • Having these plans available to treating physicians so as to incorporate them into medical decisions (Hammes B, Brasic G, Gunderson Lutheran Health System, “Planning for Future Medical Treatment: What’s Worked….What’s Failed” (406), 2010 AAHPM & HPNA Annual Assembly)

9. Advance Directive: Definition • Advance Directive: A plan, made by a capable person or their surrogate, for future medical care regarding treatments or goals of care for a possible or probable event (Hammes B, Brasic G, Gunderson Lutheran Health System, La Crosse, WI. “Planning for Future Medical Treatment: What Worked….What’s Failed” (406), 2010 AAHPM & HPNA Annual Assembly, Boston, Massuchusetts)

10. Allow patients to retain control over the life-prolonging treatment they receive. Goal of Advance Directives

11. The Conversations

12. Advance Care Planning: What May It Include • Who makes decisions • Clarification of healthcare agent’s authority • How decisions are made • Why decisions are made • When medical treatment should be stopped or avoided (“Respecting Choices”)

13. The Conversations:Establishing Goals of Care • Define choices to be made and their benefits and burdens • Help with decision-making • Develop care plans that maximize chances that desired goals will be achieved

14. Goals of Care Conversations • Review the patient’s condition, while respecting patient’s wishes for information transfer: -Current status, prognosis, treatment options -Elicit questions and concerns -Respond to emotional reactions

15. Having the Conversations:Hard Choices for Loving People by Hank Dunn An outstanding resource written for patients and their families/caregivers Not in complicated healthcare language Written by a very practical and reflective nursing home and hospice chaplain Not based on one faith or set of values Available at www.hardchoices.com

16. Hard Choices: Four Most Common Decisions 1) Should resuscitation be attempted? 2) Should artificial nutrition and hydration be utilized? 3) Should someone ill at home or in a nursing home be hospitalized? 4) Is it time to shift the goals of treatment from cure to comfort-focused care/hospice? Other decisions: use of ventilators, dialysis, antibiotics, surgery, transfusions, pain medication ( Dunn H. Hard Choices For Loving People, 2001)

17. The Conversations:Approach to Decision Making • What are the goals of the medical care? -Cure? -Stabilization of functioning? -Preparation for as comfortable and dignified a death as possible? • What outcome may we reasonably expect given the patient’s condition? -Sometimes a time limited trial will help determine if a hoped-for outcome is possible.

18. The Conversations: When evaluating interventions: Consider benefits and burdens • Will the intervention: -Help me live longer? -Improve my quality of life? -Enable me to do be more functional? -Lessen my suffering? • What are the burdens and side effects of proposed treatments?

19. Questions to Help Establish Goals of Care • “What concerns you most about your illness?” • “As you think about your illness, what is the best that might happen?” “What is the worst?” • “What are your greatest fears?” • “What are your hopes for the future?” (Quill TE. JAMA; 284:2502-7; Lo et al. Ann Intern Med; 1999: 744-9)

20. “What if things do not go as we hope they will?” “What would you be ‘unacceptable’ to you?” “What is most important to you now?”

22. Maine Health Care Advance Directive • Part 1-Choose someone to make health care decisions-Power of Attorney for Health Care (Health Care Agent/Proxy) • Part 2-Choose certain treatments • Part 3-Name your primary care clinician • Part 4-State decision about donating organs, body or tissues after death • Part 5- Choose someone to or state wishes about funeral and burial decisions • Part 6-Sign AD, 2 witnesses, notary, distribution • Part 7-Do Not Resuscitate (DNR) form

23. Standard Approach to Effort to Complete Advance Directive Does Not Work • AD low prevalence: 20-30% general population; <50% for patients with end-stage diseases • Advance directives often not available at the place of treatment (about 25% of time to physician) • Advance directives are often not helpful for decision making-too vague • Advance directives are often not followed (not available, not specific, not accepted) (Wilkinson A, Wenger N, Shugarman LR. US Dept. Health and Human Services, RAND corp. Literature Review on Advance Directives, 2008)

24. Successful Advance Care Planning Requires 5 Conditions Be Met • Plans must be created…high prevalence of population completing • Plans must be specific enough for the clinical situation • Plans must accurately reflect patient preferences and be understandable to those making decisions • Plans must be available to decision-makers • Plans must be incorporated into decisions (Fagerlin A, Scheider CE. Enough. The failure of the living will. Hastings Cent. Rep. 2004;34:30-42)

25. Physician Orders forLife Sustaining Treatment:POLST

26. Purpose of POLST To provide a mechanism to communicate patient preferences for end-of-life treatment across treatment settings

27. The National POLST Paradigm Developed at the Center for Ethics in Health Care at Oregon Health & Sciences University (OHSU) in the early 1990s; evidence-based history of effectiveness Actionable information on how to honor the wishes of a patient with a life-threatening condition regarding a range of treatments Turns patient treatment preferences and Advance Directives into medical orders Brightly colored medical order form for seriously ill patients (surprise question) Signed by physician/NP/PA (requirements may vary by state) Goal is to ensure wishes for treatment are honored Designated as a Quality indicator by the National Quality Forum

28. National POLST Paradigm Programs www.polst.org

29. POLST Resources • www POLST.org • Research, Education, Development • Educational Materials • Patient and Family Brochures

30. What is POLST ? A physician order1 Can be completed by any healthcare professional, but must be signed by a licensed physician2 Complements, but does not replace, advance directives Voluntary use, but provides consistent recognized document 1. In some states may also be a NP or PA order 2. In some states a nurse practitioner or physician assistant may sign the POLST form

31. For all adults Health care proxy form Living will Organ donation card (optional) For those who are seriously ill or near the end of life Non-hospital “Do not Resuscitate” (DNR) order Physician Orders for Life Sustaining Treatment (POLST) Advanced Care Directives: recommendations

32. Living Will * Compared to POLST For every adult Requires decisions about myriad of future treatments Statement of preferences Needs to be retrieved Requires interpretation For the seriously ill Decision among presented options Checking of preferred boxes Stays with the patient A physician’s order to be followed Living Will POLST POLST does not take the place of choosing a Health Care Agent or POA. It is helpful to appoint a POA before cognitive impairment occurs *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42.

33. Translates Wishes Into Orders:Not Necessarily to Limit Interventions • Completing a POLST does not mean the patient is adopting a palliative approach • It can be used to achieve that goal • But it also can clarify wishes for full intervention which might include intensive care and full resuscitation

34. Maine’s POLST Form (One sheet printed on both sides)

35. Section A: Must be completed HIPAA Compliant If any other section is not completed it implies full treatment for that section. Only applies if no pulse and not breathing. “Do Not Attempt Resuscitation” facilitates discussion about limited potential for success

36. Section B: Medical Interventions This section most directly influences place of care at time of death.

37. Section C: Antibiotics Option gives the choice to decide later since the issue of when to use antibiotics is complex

38. Section D: Nutrition and Hydration Nutrition Preferences Addressed Hydration Preferences Addressed

39. Section E: Basis for Orders Must be signed Basis for orders clearly identified

40. Side 2: Section F Instructions for use Patient or Authorized Representative Signature Instructions for use

41. “Authorized Representative” in Maine • In order of priority • Health Care Agent • Court Appointed Guardian • Surrogate: (in the following order) as defined in 18-A MRS • Spouse or adult who shares emotional, physical and financial relationship similar to spouse • Adult child • Parent • Adult sibling • Adult grandchild….then niece-nephew/aunt-uncle • If none, then adult who has exhibited special concern …who is familiar with the patient’s personal values

42. POLST in Maine Standardized form for Maine finalized April 2009 Needs to be printed on universally recognized color #24 lime green

43. POLST in Maine is Evolving Need to develop protocols for use in inter-institutional transfers and recognition by EMS EMS protocol for Maine; EMS has 2 different DNR forms based on patient’s capacity; Maine EMS POLST policies need to be determined; top priority for POLST Coalition National models for protection from civil or criminal liability for good faith compliance with and reliance upon POLST Other States range from legislative approaches to regulatory to voluntary best practice (most flexible model)

44. Advanced PlanningNursing Home Care • Approximately 1/3 of NH residents die after one year of admission • By 2020, 40 percent of all deaths will occur in the Nursing Home (Oliver, J Am Med Dir Assoc 2004) • 50% of all people over age 65 will spend some time in a Nursing Facility

45. Advanced PlanningNursing Home Care • Goal of Nursing Home Care • Maximize resident autonomy, function, dignity and comfort • Patient Self-Determination Act 1990 • Residents with Advanced Directives • More likely to die in Nursing Home with Hospice Care • Less likely to use a feeding tube or respirator in last month of life • Hospitalized less (Teno, J Am Geriatric Soc)

46. MMC Geriatrics POLST Initiative • Patient Care Need • Physician • Nursing • Patients • Family • Care Coordination

47. Nursing Home Characteristics Nursing Home A: 125 beds, 4 wings, dual certified, for-profit corporation, high skilled census Nursing Home B: 40 beds, “Life care Model”, non-profit, 2-5 skilled beds Nursing Home C: 50+ beds, 2 wings, dual certified, average 6-10 skilled

48. POLST Implementation • Chart Location • Duplication • Maintenance of Original Document • Transfer of Original Document • Timely Completion • Interdisciplinary Approach

49. POLST Implementation • Surrogate Decision Maker • Availability • Involvement • Understanding • Necessity • Unanimity

50. Independent POLST Implementation • Effective • Unit/Facility Champion • Culture Change • Admission RN or Social Services • Empowered NP’s • Provider Quality Metric • “Introductory” Conversation • Ineffective • Transferring Original • Partial Completion • Partial Physician Involvement • Completion on acute visits • Completion without family input • Completion without patient input