Physician Orders for Scope of Treatment: POST

1. Physician Orders for Scope of Treatment: POST Physician Training Revised 06/29/2012

2. An Index Case Mr. Jan, a 71-year-old male with severe COPD and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing SOB and decreasing LOC over 24 hours. The nursing facility staff called EMS who found the patient unresponsive, with a RR of 8 and an O2 sat at 85% on room air. Although Mr. Jan had discussed his desire to forgo aggressive, life-sustaining measures with his family and nursing personnel, the nursing facility staff did not document his preferences, inform the emergency team about them, or mention his do-not-resuscitate order.

3. After EMS was unable to intubate him at the scene, they inserted an oral airway, bagged, and transported the patient to the emergency department (2nd hospital). Mr. Jan remained unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P of 105 , RR of 8, and an O2 sat of 88% despite supplemental oxygen. He had diminished breath sounds without wheezes, and a chest X-ray showed large lung volumes without consolidation. Arterial blood gases showed marked respiratory acidosis. The emergency department physician wrote, “full code for now, status unclear.” The staff intubated and sedated Mr. Jan and transferred him to the intensive care unit. Lynn, et al. Ann Intern Med 2003;138:812-818.

4. What went wrong?(Could this happen in Virginia?) • 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. What is POST? A physician order Can be completed by any provider but must be signed by qualified MD or DO Compliments, but does not replace, Advance Directives Voluntary use Recognized by VDH/EMS as a valid DDNR

6. POST is for… Seriously ill patients* Terminally ill patients Frail and elderly. * chronic, progressive disease’s

7. Purpose of POST To provide a mechanism tocommunicate patients’ preferences for medical treatment across treatment settings To improve implementation of Advance Care Planning

8. Expected Outcomes of Using POST Process • Improved continuity of care-form transferable across treatment settings • Clearer communication of wishes • Reduced hospitalization and inappropriate life-sustaining treatments • Fewer EMS transports! • More accurate representation of preferences • Higher adherence to wishes by medical professionals.

9. Advance Directive* v. POST Advance Directive POST *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42. For the seriously ill Decisions among presented options Checking of preferred boxes Stays with the patient A physician’s order to be followed For every adult Requires decisions about myriad of future treatments Clear statement of preferences Needs to be retrieved Requires interpretation

10. Why POST Works… • MUST accompany patient • Contains specifics • Physician’s order- no interpretation is needed • POST orders are to be followed

11. POLST – POST – MOST – MOLST

12. POST Pilot Project POST was first piloted in Virginia in Roanoke beginning in 2007. Second POST pilot was in Norfolk/Virginia Beach which began in 2011. Since then POST Form pilots have expanded around the state. POST now has the endorsement from the Medical Society of Virginia. Representative from POST pilots and other stakeholders from around Virginia are represented on the Virginia POST Collaborative.

13. Virginia POST Collaborative Executive Committee Task Forces Statewide Advisory Committee Quality Improvement Regional Coalitions 8. Charlottesville 9. Winchester 10. Harrisonburg 11. Essex Co. 12. King & Queen Co. 13. Rapidan/Rappahanack Region • Roanoke Valley • Eastern Virginia • Lynchburg • Fredericksburg • Fairfax • New River Valley • Richmond 9 Professional Education 5 13 10 4 8 11 Communications & Marketing 12 7 2 3 1 2 6 Sustainability

14. POST FORM

15. Checklist… Verify ID Verify Code Status with Patient/Agent Indicate Medical Interventions, Antibiotics, Artificial Hydration/Nutrition, who discussed with and setting. Sign & date by physician, physician’s assistant § 54.1-2952.2 or nurse practitioner. §54.1-2957.02 per facility/practice protocal.

16. Verify signature of patient OR agent on behalf of patient.

17. SectionsB - D • Sections B – D are currently not covered by any Virginia Statute. • Physicians are encouraged to honor Sections B – D, provided they have examined the POST Form and find all signatures valid including the signature of a license practitioner. • Physician compliance is currently voluntary. • If you have concerns, discuss with the patient or contact the patient’s Healthcare Agent for clarification. 17

18. Section A: Resuscitation • DNR orders only apply if a person has no pulse and is not breathing • Note: This section has 2 choices: Attempt Resuscitation and Do Not Attempt Resuscitation: Check to see which box is checked! • POST Section A recognized as a valid Virginia Other DNR. • When Do Not Attempt Resuscitation is checked, qualified healthcare personnel are authorized to honor this order as if it were a Durable DNR order • OEMS approval (Michael Berg)

19. SectionB • Person has pulse and/or is breathing • Comfort Measures Only • Limited Interventions • Full Interventions – All care above plus intubation and cardioversion.

20. Section C: Antibiotics

21. Section D: Artificial Nutrition and Hydration

22. Section E • Verify signed and dated by licensed practitioner.

23. Back of Form • Signature of Patient/POA, and health care professionals completing the form. • Contact information • Directions for Health Care Professionals • Verify Patient/Agent has signed.

24. Revocation • Patient can revoke POST Form at anytime. • Agent/Family can only revoke Section A - DDNR if they signed originally on behalf of patient. • If PATIENT signed - Agent/Family CAN NOT revoke Section A DDNR. • § 54.1-2987.1.B ………In no case shall any person other than the patient have authority to revoke a Durable Do Not Resuscitate Order executed upon the request of and with the consent of the patient himself. 24

25. “Always ask if your patient might be appropriate for a POST form?”If so……… you can enter an order in eCare for a Certified POST Facilitator to assist in facilitating the completion of the form……..

26. Form Shall Always Accompany Patient/Resident When Transferred or Discharged! Place on the top of the transfer packet!

27. To Recap……………. Know what the POST form looks like. Know location of POST form in transfer records. Scan POST form into emr. Honor Code Status (SECTION A) During transfer, communicate in your handoff that patient has a POST form and the contents of all sections. At receiving facility/unit, communicate that patient has a POST form and its location. Document turnover of POST Form in your notes.

28. Take-Home Messages POST completion will improve medical treatment throughout our community. Use of POST will require communication to make it work in our community POST follows same guidelines of revocation as DDNR!

29. Questions? • The Eastern Virginia POST Coordinator – David Cochran – 757-388-5977