Minnesota’s Provider Order for Life Sustaining Treatment polstmn

1. Minnesota’s Provider Order for Life Sustaining Treatmenthttp://www.polstmn.org Edward Ratner, MD Associate Professor of Medicine, University of Minnesota Medical School Chair, Minnesota POLST Task Force ratne001@umn.edu June 2011

2. Learning Objectives To be able to: • Describe POLST history • Describe POLST in Minnesota • Prepare a Health Care Directive that can be used to create a POLST • Give legal advice regarding POLST

3. National POLST Effort • Led by Oregon • The National POLST Paradigm Initiative Task Force • Endorses state initiatives

4. Minnesota POLST History • Considered since1990’s • Minnesota Medical Association Ethics Committee considered ~ 2006 • POLST Task Force: 2007-09 • Implemented by Minnesota health systems in 2010 • Endorsed by EMSRB, MMA, and others

5. POLST Task Force • Sponsored by Minnesota Medical Association • Open to anyone interested • Invites to those participating in national POLST teleconferences • Representatives from: • Medical, nursing, health law, hospice, EMS • Metro and outstate • Started with tools used by Allina and Echo

6. Purpose of POLST in Minnesota • To provide communication of the patient’s preferences from primary care provider to EMS, ER, nurses, and doctors in case of an emergency. • Allows RNs, EMS, and doctors to act on patient preferences. • Informs until AD or agent can be consulted.

7. In Minnesota, POLST Is NOT • A contract • Defined in statute • Binding from one doctor to another • Unchangeable • An order of a legal court • A piece of paper

8. Target patients for POLST Intended for those in last 1 to 2 years of life including: • all hospice enrollees • long-term nursing home residents • assisted living facility residents • other high-risk institutionalized populations

9. Minnesota POLST Form Title: Provider Order…. (not physician) Section A: CPR preferences Do Not Resuscitate (DNR), also referred to as Allow Natural Death Section B: Goals of treatment • If not to be hospitalized, what alternatives? • If hospitalized, what interventions are to be pursued-comfort care, intubation, etc.

10. Minnesota POLST Form (continued) Section C: Interventions and Treatment Antibiotics Hydration Nutrition Section D: Summary of Goals Discussed with The basis for these orders is Section E: Signatures: Must be signed by the patient or guardian

11. POLST Signatures • Required: • Person completing (e.g. RN/SW/Chaplain) • MD/NP/PA signature • Optional: • Patient/Surrogate • Ethically and legally not required • Some institutions do require, however

12. Health Care Directives (HCD)and POLST If POLST is based upon HCD, agent and medical provider have legal protection under Minnesota law.

13. 145C.11 IMMUNITIES.Subdivision 1.Health care agent. • A health care agent is not subject to criminal prosecution or civil liability if the health care agent acts in good faith.

14. 145C.11 IMMUNITIES.Subd. 2.Health care provider • (a) With respect to health care provided to a patient with a health care directive, a health care provider is not subject to criminal prosecution, civil liability, or professional disciplinary action if the health care provider acts in good faith and in accordance with applicable standards of care.

15. 145C.11 IMMUNITIES.Subd. 2.Health care provider (b) A health care provider is not subject to criminal prosecution, civil liability, or professional disciplinary action if the health care provider relies on a health care decision made by the health care agent and the following requirements are satisfied:

16. 145C.11 IMMUNITIES.Subd. 2.Health care provider (1) the health care provider believes in good faith that the decision was made by a health care agent appointed to make the decision and has no actual knowledge that the health care directive has been revoked; and (2) the health care provider believes in good faith that the health care agent is acting in good faith.

17. 145C.11 IMMUNITIES.Subd. 2.Health care provider (c) A health care provider who administers health care necessary to keep the principal alive, despite a health care decision of the health care agent to withhold or withdraw that treatment, is not subject to criminal prosecution, civil liability, or professional disciplinary action if that health care provider promptly took all reasonable steps to:

18. 145C.11 IMMUNITIES.Subd. 2.Health care provider (1) notify the health care agent of the health care provider's unwillingness to comply; (2) document the notification in the principal's medical record; and (3) permit the health care agent to arrange to transfer care of the principal to another health care provider willing to comply with the decision of the health care agent.

19. Health Care Directives and POLST • If patient is “competent” and high-risk, do both HCD and POLST • Without HCD, POLST clarifies and communicates – but is not legally protective for family member or provider

20. Implications for Lawyers • Advise clients to create HCD when patient is competent. • Write HCD to address POLST issues. • Name agent, give broad powers. • Leave instructions blank; OR address specifics of resuscitation, feeding tubes, and other invasive treatments. 3. Discuss POLST issues with agent.

21. Implications for Lawyers (continued) 4. Advise POLST when illness is advanced • Patient when competent • Family/named agent/conservator 5. Advise agents and families as POLST forms acted upon, before and after death 6. Comfort families after deaths

22. Summary • After long wait, Minnesota has POLST. • POLST complements HCD near the end of life. • Elder law professionals have multiple roles related to POLST. • Forms available at http://www.polstmn.org.