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POST . Physician Orders for Scope of Treatment

2. An Index Case. Mr. Jan (a pseudonym), a 71-year-old man with severe chronic obstructive pulmonary disease and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing shortness of breath and decreasing responsiveness over 24

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POST . Physician Orders for Scope of Treatment

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    1. 1 POST…. Physician Orders for Scope of Treatment

    2. 2

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    4. 4 What went wrong? (Could this happen in Asheville?) Advance directives not documented DNR order not communicated in transfer Fragmentation in care (2 hospitals) Overtreatment against patient’s wishes Unnecessary pain and suffering System-wide failure to respect pt’s wishes Failure to plan ahead for contingencies No system for transfer of plan

    5. 5 Initial Planning WV Initiative to Improve End-of-Life Care June 1998 “When my time comes, I want the system to have it right!”

    6. 6 Preferences of WV Patients What would having the system right look like?

    8. 8

    9. 9 What is POST? A physician order Can be completed by any provider but must be signed by qualified MD or DO Complements, but does not replace, advance directives Voluntary use

    10. 10 POST is for… Seriously ill patients* Terminally ill patients

    11. 11 Prompt for POST Completion

    12. 12 Purpose of POST To provide a mechanism to communicate patients’ preferences for end-of-life treatment across treatment settings To improve implementation of advance care planning

    13. 13 Basis of POST Encourages discussion with patient and family or surrogate decision maker of key end-of-life care issues

    14. 14 Needed for Completion Patient with decision-making capacity or Activation of Medical Power of Attorney Appointment of Health Care Surrogate Discussion by physician or designee

    15. 15 Living Will* Compared to POST For every adult Requires decisions about myriad of future treatments Clear statement of preferences Needs to be retrieved Requires interpretation For the seriously ill Decisions among presented options Checking of preferred boxes Stays with the patient A physician’s order to be followed

    16. 16 The Rationale for POST AD may not be available when needed AD may not have prompted needed discussion and may not be specific enough No provision for treatment in the NH or home May not cover topics of most immediate need AD may be overridden by a treating MD AD does not immediately translate into MD order

    17. 17 Why POST Works By law MUST accompany patient Contains specifics It IS a physician’s order—no interpretation is needed and POST orders are to be followed

    18. 18 The Present Approach: Planning to Fail “…the health care system virtually ensures that treatment will NOT follow patients’ preferences once patients want palliative care rather than intubation and intensive care.”

    19. 19 Two types of advance directives Basic-little or no impact on immediate care Living will Do not resuscitate order Progressive-direct and relatively immediate impact on course of care POST form Do not hospitalize, no feeding tube, etc.

    20. 20 A System-wide Approach Different settings Hospital Nursing Home Home Ambulance Uniform response Document that indicates specific responses to various likely complications Avoidance of “error” Failure of planned action to be completed as intended

    21. 21

    22. 22

    23. 23 Advance Care Planning circa 2000 Identification of Medical Power of Attorney Goals of treatment Cardiopulmonary resuscitation (CPR) Feeding tubes Mechanical ventilation Dialysis Organ and Tissue Donation Preferred site of death and those present at death

    24. 24 Definitions Advance Directives * Living Will Medical Power of Attorney Do Not Attempt Resuscitation-DNR card Surrogate POST – Physician Orders for Scope of Treatment * *Indicates need to have these items in appendices*Indicates need to have these items in appendices

    25. 25 Broadening Our Understanding of Advance Care Planning Advance care planning is a process in which patients… Learn options for care Discuss wishes for care with family and MD Complete advance directive and POST form Have wishes respected when the time comes

    26. 26 Broadening Our Understanding of Advance Care Planning Advance care planning is a process in which patients… Learn options for care Discuss wishes for care with family and MD Complete advance directive and POST form Have wishes respected when the time comes

    27. 27 Communication across Settings “…the health care facility initiating the transfer shall communicate the existence of the POST form to the receiving facility prior to the transfer. The POST form shall accompany the person to the receiving facility and shall remain in effect.” Code of West Virginia, §16-30-1 et seq.

    28. 28 Development of the POST Oregon experience Review of end-of-life decision making in West Virginia Collaborative effort through the West Virginia Initiative to Improve End-of-Life Care Voluntary process Codified by West Virginia Legislature *need list of members and organizations (I.e., roster) for appendix*need list of members and organizations (I.e., roster) for appendix

    29. 29 Validation of POLST Dunn PM, Schmidt TA, Carley MM et al: A method to communicate patient preferences about medically indicated life sustaining treatment JAGS 1996;44:785 Tolle SW, Tilden VP, Nelson CA, Dunn PM: A Prospective study of the efficacy of the POLST JAGS 1998;46:1097 Lee MA, Brummel-Smith K, Meyer J et al: Physician orders for life-sustaining treatment (POLST): Outcomes in a PACE program JAGS 2000; 48:1-6. Schmidt TA, et al: The POLST Program: Oregon emergency medical technicians’ practical experiences and attitudes. JAGS 2004; in press. Hickman SE, et al: Use of the POLST Program in Oregon Nursing Facilities: Beyond resuscitation status. JAGS 2004; in press. *Include all articles in appendix*Include all articles in appendix

    30. 30 Legal Protection with POST Use Standardized form according to state law Legally recognized DNR identification Protection from civil or criminal liability for good faith compliance with and reliance upon POST Protocol for use in interinstitutional transfers Law covers compliance with POST when completed by MD not credentialed in facility

    31. 31 Section A: Resuscitation DNR orders only apply if a person is pulseless and apneic

    32. 32 Section B Comfort Interventions Only Additional Interventions Full Treatment/Resuscitation – All care above plus intubation and defibrillation

    33. 33 If patient chooses comfort… Review plan of care to be sure that palliative care measures are in place Institute palliative care measures as needed If you would not be surprised if the patient died in six months, consider hospice

    34. 34 Section C No Antibiotics Antibiotics

    35. 35 Section D Medically Administered Fluids and Nutrition No feeding tube/IV Fluids Feeding Tube/IV Fluids for a Defined Period Long-term feeding tube/IV fluids

    36. 36 Section E Discussed with Patient/resident MPOA representative Court-appointed guardian Health care surrogate Spouse Parent of minor Other (specify)

    37. 37 Section E The Basis for These Orders is: Patient’s preferences Patient’s best interest Other Physician Name, Phone Number, and Signature Date

    38. 38 Section F Preferences as a Guide for the POST Form Advance Directives Organ/Tissue Donation Document of Gift Court-appointed Guardian Patient, Parent, MPOA, Guardian, or Representative/Surrogate Signature Person Preparing Form Name and Signature Date Prepared

    39. 39 Section G Review of POST Date Reviewer Location of Review Outcome of Review

    40. 40 Strategies for Implementation, I Completion of POST is part of disposition planning Think POST at time of transfer or discharge Add POST to discharge checklist Complete POST when discharging to a NH or home with home care or hospice Educate NHs and EDs to send POST and look for POST respectively Educate EMS

    41. 41 Strategies for Implementation, II Work with NH social workers and nurses Encourage them to complete POST form on admission for residents Encourage them to complete/update POST at time of quarterly care planning Encourage them to always send POST to hospital on transfer Be sure to send POST back with patients!

    42. 42 “Where is the POST form?”

    43. 43 Original Form Shall Always Accompany Patient/Resident When Transferred or Discharged!

    44. 44

    45. 45 Goal is to Improve Care Measure outcomes Determine patterns of care Provide feedback Revise system as needed

    46. 46 Take-Home Messages POST provides a better means than AD to identify and respect patients’ wishes POST completion will improve end-of-life care throughout the system Use of POST will require communication to make it work in your community “Where’s the POST form?”

    47. 47 www.wvendoflife.org Toll-free 1-877-209-8086

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