Transcript What is POLST and Why Should I Care?

What is POLST and Why Should I Care?
COLC Monthly Seminar
3 May 2012
Dr. Dan Kimball
Ms. Elizabeth Moreli, ESQ.
What Most People Want at End-of-Life
 Respect my uniqueness as an individual
 Provide me with peace and comfort
 Address my spiritual needs
 Recognize my cultural heritage
 Communicate with me
 Help me with my pain (physical and emotional)
 Don’t prolong my dying
 Give me a sense of control
 Relieve the burden on my loved ones
 Touch
What does POLST mean?
P
-
Physician (or Pennsylvania)
O
-
Orders for
L
-
Life
S-
Sustaining
T
-
Treatment
History of POLST in PA

2000 - Provider Task Force to Improve Care at the End-of-Life convened
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2002 - Pittsburgh End of Life Collaborative, a quality improvement initiative
within fourteen nursing homes. Funded by Highmark, UPMC and the Jewish
Healthcare Foundation

2004 - Susan Tolle MD, of the Oregon Health Sciences University Department of
Ethics and a leader in the launching of POLST, spoke to group of community
leaders
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2004 - Coalition for Quality at the End of Life (CQEL) established
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2006 – Passage of Act 169
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2007 - As mandated by Act 169, the Pennsylvania Department of Health Patient
Life-Sustaining Wishes Committee convened

October 2010 - POLST approved by Pennsylvania Secretary of Health

January 2011 - Endorsed by the National POLST Paradigm Task Force
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So, What is a POLST form?
A document that helps doctors, nurses, healthcare
facilities and emergency personnel honor patient
wishes regarding life-sustaining treatments in
emergency situations.
Goal is to improve the quality of care people
receive at the end of life by turning Patient Goals
and Preferences for care into Medical Orders.
HIPAA
Compliant
Cardiopulmonary
clarifies type of
resuscitation. Do
Not Attempt
Resuscitation
assists clinicians
in communicating
odds about
success
Options
give people
the choice
to decide
later since
issue of
when to use
antibiotics
is complex
Discussion
about
treatment
preferences
is required
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PENNSYLVANIA FORM
Clear
instruction on
when to
transfer to
hospital and
use of
intensive care
IV fluids in
Limited
Additional
Interventions
section
Artificial
hydration and
artificial
nutrition both
found here
If any section
left unmarked,
the highest
level of
treatment must
be provided
PENNSYLVANIA FORM 2ND SIDE
.
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More about POLST forms
This is a voluntary process!
 For individuals with advanced chronic progressive
illness and/or frailty!
(I would not be surprised if this patient were to die
within the next 12 months)
 For individuals who desire to further define their
preferences for care in their present state of ill-health
 This is an extension of the Advance Directive Process
for appropriate individuals

What issues are included in POLST?
 Preferences related to Resuscitation
 Preferences for levels of Medical Care
 Preferences for the use of antibiotics
 Preferences for the use of artificial administration of fluids and/or
nutrition (i.e., IV fluids and/or feeding tube)
Who Completes the POLST Form?
 Physician, Nurse Practitioner, Physician Assistant can complete but




must sign the form.
Actual completion of the form may be done by other health
professionals (i.e., nurses, social workers)
Completed only after an appropriate discussion with the patient
and/or surrogate decision maker.
The document is also signed by the patient or the surrogate decision
maker.
It then becomes a “Medical Order” that can be understood and
followed by other professionals.
Where can POLST be used?
Remains with patient in their setting (home, hospice,
skilled nursing facility, long term care facility, personal
care facility, or hospital).
 In facility, form kept on “medical chart” or record!
 At home, kept in prominent place (refrigerator, bedside
table, or medicine cabinet).
 Travels with patient where ever they go!
 The bright pink color is to make the form obvious to any
professional picking up the chart.

A POLST form is not….
 An Advance Directive
(you can execute a POLST without a preceding
Advance Directive)
 In conflict with the Advance Directive
 To take the place of a Health Care Agent
 To take the place of a Health Care Representative
 Required by any institution, law or regulation; it is
completely voluntary
Legal Requirements for POLST Form
 Must include the patient’s name.
 Section A (Resuscitation status) must be completed.
 Signature by Physician, CRNP or PA.
 Physician countersignature for CRNP and PA.
 Sections B, C and D are optional.
 Patient Signature preferred (institutional guidance).
Limitations of POLST completed by someone other
than patient or Health Care Agent
Neither a health care representative (as distinguished
from a health care agent or health care power of attorney)
nor a guardian of the person may decline care necessary
to preserve life unless the patient is in an end-stage
medical condition or is permanently unconscious.
Suggestions for Periodic Review of POLST





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Yearly or semi-yearly (institutional guidance will control); at plan
of care meetings, etc.
With any significant change in health status
With change in care setting or level of care
With change in patient preferences for care
At request of patient or patient surrogate decision maker
Improved patient condition
Advance worsening condition to permanent unconsciousness
Differences between POLST
and Advance Directives
Characteristics
POLST
Advance Directives
Population
For the seriously ill
All adults
Timeframe
Current care
Future care
Who completes the form
Health Care Professionals Patients
Resulting form
Medical Orders (POLST)
Advance Directives
Health Care Agent or
Surrogate role
Can engage in discussion
if patient lacks capacity
Cannot complete
Portability
Provider responsibility
Patient/family
responsibility
Periodic review
Provider responsibility
Patient/family
responsibility
Bomba PA, Black J. The POLST: An improvement over traditional advance directives.
Cleveland Clinic Journal of Medicine. In press.
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Where Does POLST Fit In?
Advance Care Planning Continuum
Age 18
Complete an Advance Directive
Update Advance Directive Periodically
Diagnosed with Serious or Chronic, Progressive
Illness (at any age)
Complete a POLST Form
Treatment Wishes Honored
Out-of-Hospital DNR
EMS providers may only follow a PA
OOH-DNR order, bracelet, or necklace
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Checklist for POLST Program

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Policy Development by all Healthcare Facilities
 For Advance Directives and POLST
 Process for Review of both and addressing conflicts
 To accept POLST orders from transferring facility
Education Plan (Staff; Physicians; Patients)
Notification of key contacts (EMS; Hospitals)
Program Implementation (new pts; partial use; full use)
Quality Improvement (Audits and feedback)
Selected Challenges
 Measuring the quality of the conversation underlying ACP
and POLST.
 Training health care providers (Facilitators).
 Decision-making for those who have no appointed proxy.
 Educating health care agents/proxies.
 Evaluating protections for vulnerable population.
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POLST Website Resources
http://www.aging.pitt.edu/professio
nals/resources.htm
Aging Institute of UPMC Senior
Services and the University of
Pittsburgh
www.polst.org
Center for Ethics in Health Care
Oregon Health & Science University
http://www.aarp.org/ppi
AARP Public Policy Institute