Minnesota’s Provider Order for Life Sustaining Treatment

http://www.polstmn.org

Edward Ratner, MD Associate Professor of Medicine, University of Minnesota Chair, Minnesota POLST Task Force [email protected]

October, 2010

Learning Objectives

To be able to: • Describe POLST in Minnesota • Assist medical providers by completing POLST documents for their signature • Appropriately follow POLST when signed by eligible medical providers

Purpose of POLST in Minnesota

• Communicate from medical provider to EMS, ER, nurses, doctors, and home care nurses.

• Operationalizes written advance directive and surrogate statements • To inform until AD or surrogate can be re-consulted (e.g. 24-48 hours) • For those in last one to two years of life

Minnesota POLST History

• Considered since 1990’s • Hennepin County since mid 1990’s • Minnesota Medical Association Ethics Committee Considered ~ 2006 • POLST Task Force – 2007-09 • Implemented by Minnesota health systems in 2010

Minnesota POLST Form

• Title: “Provider Order….” (not physician) • Section A: Cardiopulmonary Resuscitation – CPR versus DNR, aka Allow Natural Death • Section B: Goals of treatment – Comfort care only; hospitalization alternatives?

– Limit interventions such as intubation; treat of reversible illness or injury – Provide life sustaining treatment • Section C: Interventions and treatment – Antibiotics – Hydration – Nutrition

Minnesota POLST Form

(continued) • Section D: Summary of goals – Discussed with: patient, healthcare agent, other, none – The basis for these orders is patient’s: request, known preference, healthcare directive or living will, best interest, other – Contact information of form preparer • Section E: Signatures – Provider signature (required) – Patient or health care agent/guardian/surrogate

Completing a POLST in a senior housing setting

• Can be performed by RN, SW, chaplain • Best if based on discussions with patient or legal surrogate • May not be accepted by medical providers if based on: – “Known preference” or “Best Interests”, unless through legal surrogate – Interpretation of Health Care Directive only

POLST Signatures

• RN/SW/Chaplain name and signature

required

• Patient/Surrogate signature valuable but not required • Send copy of POLST to MD/NP/PA for signature – with Health Care Directive, if available

HCD and POLST

• If POLST completed based upon HCD, medical provider has legal protection when preferences honored.

• If patient competent, do both (if L.E. < 2 yrs) • Without HCD, POLST clarifies and communicates – but not legally protective

Following a POLST in Senior Housing

• Requires institutional policy and procedure • CPR/DNR applies only if pulseless • Comfort Care – comfort orders + options to avoid (not forbid) evaluation by EMS or ER

Following a POLST (continued)

• Intubation – rarely relevant • Provide L.S.T. - call 911 & transport to ER for acute, severe problems • Antibiotic options helpful for acute fever management • Nutrition/hydration options important in end-stage neurological disease

Summary

• After long wait, Minnesota has POLST • POLST complements ADs near the end of life.

• Home care professionals have multiple roles related to POLST • Forms available at http://www.polstmn.org