Physician Orders for Life Sustaining Treatment (POLST)

1. Physician Orders for Life Sustaining Treatment (POLST)

2. Presenters: Sally Denton, BSN, RNC President/Administrator St. Joseph Care Center

3. What is POLST? • “Portable” physician orders for end-of-life care • Replaces EMS-No CPR form • Travels with patient • Can translate an Advance Directive into physician’s orders • REMEMBER: Conversations for goals of care come first! • REMEMBER: Power and Portability

4. Philosophy of POLST • Individuals have the right to make their own health care decisions • These rights include: • Making decisions about accepting or refusing life sustaining treatment • Having their decisions honored by health care providers • Comfort care while having wishes honored

5. Initiating POLST in Washington • Community Forum and RENEW (Regional Ethics Network of Eastern Washington) January, 2000 • DSHS Task Force and surrogate decision making issues • WSMA PACE grant

6. POLST Pilot Program • Washington State Department of Health and EMS training • Training for 24 SNFs with DSHS support • Hospitals: Policies and Procedures • Physician education and recruitment

7. Pilot started August 2000 6 SNF, 21 patients Evidence of informed consent Congruence of stated wishes with completed POLST POLST Pilot Program, cont.

8. POLST Pilot Program, cont. • Washington DOH accepts POLST for statewide use and commits to EMS training • WSMA commits to physician and consumer POLST education • WSHA and AWPHD adds POLST to End-of-Life Hospital Resources and actively promotes POLST education and implementation • DSHS notifies residential care facilities of use of POLST

9. How POLST Works

10. POLST vs. EMS Form • Both forms: • Are physician orders recognized by Washington DOH and EMS (911) • Allow “Do Not Resuscitate” choice if no pulse or respirations • Only POLST includes orders for medical interventions when person has pulse and/or is breathing

11. POLST: Who Should Have One? • Anyone choosing: • Do not resuscitate • No code • Allow natural death • Anyone choosing to limit medical interventions • Anyone “you anticipate might die within the next year”

12. POLST Form Part A • Resuscitation: Includes EMS • Patient has no pulse and is not breathing • Resuscitate • Do Not Resuscitate (allow natural death) • Comfort measures will always be provided

13. POLST Form Part B • Medical Interventions:Person has pulse and is breathing. • Comfort Measures Only: Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction as needed for comfort. • Limited additional interventions: Includes care described above. Use medical treatment, IV fluids and cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. • Full Treatment: Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. • Additional Orders: (e.g. dialysis, etc.) __________________

14. POLST Form Part C • No Antibiotics. Use other measures to relieve symptoms. • Determine use or limitation of antibiotics when infections occurs, with comfort as goal. • Use antibiotics if life can be prolonged.

15. POLST Form Part D • No Artificially Nutrition by tube • Trial period of artificial nutrition by tube. (Goal:__________) • Long-term artificial nutrition by tube • Additional orders:____________________________

16. POLST Form Part E • Discussed with: • Patient/Resident • Agent of DPOAH • Court-appointed guardian • Spouse • Other (Specify) • Parent of minor

17. POLST Form Part E, continued • The basis for these orders is: • Patient’s request • Patient’s known preference • Patient’s best interest • Medical futility

18. POLST: Signatures • Documents informed consent process • Requires physician signature • Requires patient/resident or legal surrogate signature • Signatures are the most common logistical problem!

19. POLST: Who Fills It Out? • Physician or physician designee • Signatures attest to the informed consent process having occurred • Different facilities designate/train different personnel for this purpose

20. Transfer • Original bright lime green form • Transferred with individual to be valid (Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid.) • Health care institutions • Keep duplicate copy in permanent medical record upon discharge • Also make copy prior to inter-facility transports

21. Revocation of forms • Patient • Verbally revoking order • Destroying form and/or No CPR bracelet • Physician or legal surrogate expresses patient’s revocation • Line out “physician orders” • Write “VOID” then initial

22. POLST in Hospitals • POLST forms may be initiated in hospitals • Sample policies and procedures are available • Form must be visible in chart • Staff must be trained and updated on interaction with other end-of-life documents

23. POLST in Skilled Nursing Facilities • Policy describing POLST use required • New resident • SNF can honor POLST for up to two weeks • Review during first comprehensive assessment period • On review • Document that form contains current wishes OR • Complete new form

24. Physicians and POLST • Washington State Medical Association • Form appropriate for: • Patient you would not be surprised if they died within the next year • Any patient choosing to limit medical interventions (encourage family conversations) • Local educational efforts

25. POLST in the Community

26. Integrating POLST in the Community • EMS service providers trained • Hospitals update policies to address POLST • Nursing homes also update policies--surrogate decision making issue may arise • Physicians trained

27. Integrating POLST in the Community-Continued • Training for hospital and nursing home staff • Other entities and persons • assisted living • adult day health • estate planning attorneys • Other awareness activities for the community

28. Helpful Hints on Integrating POLST in the Community • Establish a “Go Date” • Hospitals and nursing homes can meet to draft consistent policies • Hold a community-wide preparedness meeting

29. POLST Resources

30. POLST Resources: Required Training • Emergency Medicine and Trauma Prevention, Department of Health • Phone (360) 705-6700 • www.doh.wa.gov/hsqa/emtp/ • Provides required EMS service provider training

31. POLST Resources: Forms • Graham Short, Washington State Medical Association • Phone (206) 956-3649 • E-mail gfs@wsma.org

32. POLST Resources: Information, Policies, and Procedures • Association of Washington Public Hospital Districts web site • www.awphd.org/resources_endoflife.asp • Washington State Department of Health • http://www.doh.wa.gov/hsqa/emtp/resuscitation.htm

33. Questions