Transcript Physician Orders For Scope Of Treatment: The Roanoke Pilot

Physician Orders For Scope Of
Treatment:
The Roanoke Pilot Project for POST
Karen Mayhew, LCSW
Director of Patient Services, Good Samaritan Hospice
Missy Ring, RN, CHPN
Clinical Team Leader, Carilion Clinic Hospice
Advance Care Planning:
A Work in Progress
In hospice care, we have
long known, as said by
Bill Moyers in On Our
Own Terms, the
importance of
recognizing two things:
the individuality of each
disease and the
individuality of the
person with that
disease.
Could This Happen In Roanoke?
Mr. Dehart, a 71 year old hospice patient with severe
COPD and mild dementia, resides at home with his
wife. He develops increasing SOB and his wife calls
911. When EMS arrives, the adult daughter, visiting
from out of town, advises them the family wants
everything done. The wife does not mention her
husband’s DDNR. EMS staff, having found the
patient unresponsive, try to intubate him, but cannot.
They insert an oral airway and transport the patient to
the ER. Mr. Dehart remains unresponsive with a RR
of 8 and an O2 sat of 85% despite supplemental O2.
Pursuant to a chest X-ray, the ER physician writes,
“full code for now, status unclear.” The staff intubate
Mr. Dehart and transfer him to the intensive care unit.
What Went Wrong?
What Went Wrong?
 DDNR order not communicated to EMS and in
subsequent transfer.
 Advance directive not documented.
(Do you think advance directive would have been
followed in this situation if it were documented?)
 Family at odds with patient’s wishes.
 Lack of communication between healthcare providers
– hospice left out of loop.
 Results include overtreatment of patient with
unnecessary physical discomfort, costs, and
prolonged dying process.
“ The problem with communication is the
illusion that it has been accomplished.”
- George Bernard Shaw
Common Issues With Advance Directives
 Advance Directives (AD) frequently use
statutory language that can be hard to
understand.
 Healthcare staff trying to assist patients in
completing an AD often focus on how to
complete the form, not adequately discussing
the issues at hand.
 Focus has been more on legal rights and less
on help for patient in making informed
decision about his/her individual care.
Advance Care Planning:
Addressing The Communication Gap
 12 States have already implemented pilot programs
for POST, or a similarly named document (e.g.,
POLST/MOST), in order to close gap between patient
wishes and actual treatment:



Physician’s order greatly increases likelihood of
adherence to patient wishes.
POST document must accompany patient from one
healthcare provider to the other.
POST better informs healthcare staff of patient wishes
in that it identifies clear, specific choices . . . less room
for interpretation.
What is POST?
 Physician-signed order for communicating and
implementing patient preferences for end-of-life treatment.
 Short summary of actual treatment preferences,
including CPR, need for hospitalization & related
procedures, antibiotics, artificial nutrition and hydration.
 Approved as a legal durable DNR by the Virginia EMS
office. Is in keeping with Virginia Health Care
Decisions Act. Can stand alone as a healthcare
document or in conjunction with advance directive
 Encourages centralizing of patient’s pertinent
healthcare information, e.g., living will, Medical POA,
organ and tissue donation, etc.
 Provides for standard method of transfer across
treatment settings.
Who Is Eligible For POST?
Seriously ill persons,
i.e., those with
chronic, progressive
disease
2. Terminally ill persons
1.
Who Is Eligible For POST?
Prompt for POST completion:
Would I be surprised
if this patient
died in the next year?
Living Will vs. POST
(Remember: Patients may have both forms.)
 Living Will*
 For every adult
regardless of health
 Decisions about
open-ended myriad
of treatments
 Needs to be retrieved
 Normally requires
interpretation
(*Hastings Center Report 2004; 34: 30 – 42)
 POST
 For seriously or
terminally ill adults
 Decisions among
presented treatment
options
 Stays with patient
 Physician’s order for
specific treatment(s)
Roanoke Pilot Program
for POST
Roanoke Pilot Program for POST
 Has been developed under auspices of the Palliative
Care Partnership of the Roanoke Valley
(www.pcprv.org).
 Training in advance care planning and facilitation of
the POST form is being provided by Respecting
Choices (RC), a nationally recognized program of the
Gundersen Lutheran Medical Foundation.
 In the Roanoke area, currently 35 healthcare
professionals have been trained as Advance Care
Planning Facilitators through RC.
 The POST pilot project in Roanoke is scheduled to
begin 9/1/09 and will continue over the next 2 years,
with the goal of making POST a legal document
recognized throughout Virginia.
Roanoke Pilot Program for POST
Important Note: Only patients who reside in the
following locations are eligible to participate in
the POST pilot program:
 Roanoke County
 Friendship Health & Rehab Center
 Richfield Recovery & Care Center
Who Is Participating In The Pilot?
 Palliative Care




Partnership of the
Roanoke Valley
Friendship Health and
Rehabilitation Ctr.
Richfield Recovery and
Care Ctr.
Carilion Clinic:
Roanoke Memorial
Hospital
Lewis-Gale Hospital
(pending approval)
 4 Area Hospices
 Amedysis Hospice
 Carilion Clinic Hospice
 Good Samaritan
Hospice
 Medi Home Hospice
 Medical College of VA
(MCV) in Richmond is
also linking to RKE pilot
program
Other Participants: EMS & Local
Medical Transport Companies
 Roanoke City Fire & Rescue
 Roanoke County Fire & EMS
 Salem Fire & EMS
 Carilion Clinic Patient Transport
 Guardian
 Life Care
 United Ambulance Service
POST Form
The Conversation
 POST discussions must be facilitated by the patient’s
physician or a trained Advance Care Planning
Facilitator (ACPF). The facilitator may choose to
involve other members of the patient’s healthcare
team as well.
 The dialogue may or may not result in the completion
of a POST document, but it does create an
environment of shared and informed decision making
for the patient facing serious illness.
Role of ACP Facilitator
1.
2.
3.
4.
5.
6.
Explores patient’s understanding of advance care
planning and the role of a healthcare representative.
Explores understanding of medical condition,
including possible complications that may occur.
Provides meaningful context for decision making
through identifying previous key healthcare
experiences, fears & worries, values, and important
beliefs.
Explores patient’s understanding of CPR, comfort
care, antibiotics, artificial nutrition and hydration, etc.
Ensures that patient’s wishes are clearly documented
on transferable form.
Develops list of pertinent questions that may involve
physician and others.
The POST Form
21
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Section B: Medical Interventions
B
 one only
Comfort
Measures
are always
provided,
regardless
of the level
of care
chosen
MEDICAL INTERVENTIONS: Patient has pulse and / or is breathing.
 Comfort Measures: Treat with dignity and respect. Keep warm and dry. Use medication by any route,
positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual
treatment of airway obstruction as needed for comfort. Transfer to hospital only if comfort needs cannot be met
in current location. Also see “Other Instructions” if indicated below.
 Limited Additional Interventions: Include comfort measures described above. Do not use intubation or
mechanical ventilation. May consider less invasive airway support (e.g., CPAP or BiPAP). Use additional medical
treatment, antibiotics, IV fluids and cardiac monitoring as indicated. (Hospital transfer if indicated. Avoid
intensive care unit.) Also see “Other Instructions” if indicated below.
 Full Interventions: In addition to Comfort Measures above, use intubation, mechanical ventilation, cardioversion
as indicated. Transfer to hospital if indicated. Include intensive care unit. Also see “Other Instructions” if
indicated below.
Other Instructions:
• If in the “terminal” phase, POST and advance directive should
be consistent
• Care plan should always be consistent with POST
• If Comfort Measures are selected consider hospice
consultation
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Section A: Resuscitation
A
 one only
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
☐ Attempt Resuscitation
☐ Do Not Attempt Resuscitation (DDNR/DNR/No CPR)
A DNR order in this section qualifies as a Durable DNR order. 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. § 54.1-2987.1.B
• 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)
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Levels of Medical Interventions
 Comfort Measures
 Treat with dignity and respect.
 Keep warm and dry.
 Use medication by any route, positioning, wound
care and other measures to relieve pain and
suffering.
 Use oxygen, suction and manual treatment of
airway obstruction as needed for comfort.
 Transfer to hospital only if comfort needs cannot
be met in current location. Also see “Other
Instructions” if indicated below.
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Levels of Medical Interventions
Limited Additional
Interventions

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

Include comfort measures.
Do not use intubation or
mechanical ventilation.
May consider less invasive
airway support (e.g., CPAP
or BiPAP).
Use additional medical
treatment, antibiotics, IV
fluids and cardiac
monitoring as indicated.
Hospital transfer if
indicated. Avoid intensive
care unit. Also see “Other
Instructions” if indicated
below.
Full Interventions




In addition to Comfort
Measures above
use intubation, mechanical
ventilation, cardioversion
as indicated.
Transfer to hospital if
indicated. Include
intensive care unit.
Also see “Other
Instructions” if indicated
below.
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Section C: Artificial Nutrition
• These orders pertain to a person who cannot
take food by mouth
• Feeding tube for a defined trial period:
•
Gives option to determine benefit to patient and/or
recovery from stroke, etc.
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POST Sections (Other)
 Discussed with
 Physician (or PA or NP) Signature and
contact info
 Patient/Authorized Decision Maker
 Authority
to sign patient if patient is
incapacitated
 Facility of POST form origin
 Name and signature of Facilitator
 Instructions
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Questions???
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No problem . . .
My colleague, Missy, will be glad to answer
that!
Location And Transfer
Of POST Form
Location Of The POST Form
 The original POST form (canary yellow color)
must always accompany the patient when
transferred or discharged.
 The POST form is transferred in a large red
envelope, which stays with the original document
(see next slide).


In Nursing Facility: Will be kept in the very front
of patient’s chart.
In Patient’s Private Residence: should be kept
on refrigerator door, either in red envelope or with
easy access to red envelope.
The Red Envelope for Transfer/Discharge
Envelope Label
ORIGINAL
POST/DDNR
Form Enclosed
Form is to accompany Resident upon
Discharge/Transfer
PLEASE RETURN ORIGINAL
FORM IN THIS ENVELOPE
TO:
(Patient Name)
(Address)
Transfer Of POST With Patient
 Red envelope with original POST should be
placed on top of transport papers.
 The healthcare facility initiating the transfer
shall communicate the existence of the POST
form to the receiving facility prior to the
transfer.
 The POST form shall accompany the person
to the receiving facility and shall remain in
effect.
Modifying POST Decisions
Revoking/Making Changes to
POST
•
If the resident wishes to change the POST form,
the original POST form shall be voided, and a
new one completed.
Revoking/Changing a POST Form
• To change POST, the current POST form must
be voided and a new POST form completed. If no
new form is completed, full treatment and
resuscitation may be provided.
• As long as the patient can make his/her own
decisions, then the patient can revoke consent for
POST and also may request changes to POST.
Revoking/Making Changes to
POST
•
•
If a patient tells a healthcare professional that
he wishes to revoke his consent to POST or
change POST , the healthcare professional
caring for the patient should draw a line
through the front of the form and write “VOID”
in large letters on the original, with the date
and their signature, and notify the patient’s
physician. A new POST form then may be
completed if desired by the patient.
The physician or a POST ACPF may complete
the new form.
Revoking/Changing POST
• If “Do Not Attempt Resuscitation” is checked in
Section A and the patient has signed this form,
no one has the authority to revoke consent for
the DDNR order other than the patient as
stated in the Code of Virginia section 54.12987.1.
Revoking/Changing POST
If the patient signs this form, then the patient’s
overall treatment goals should be honored if the
patient later becomes unable to make decisions.
•If the patient is unable to make healthcare
decisions, a legally authorized medical decision
maker, in consultation with the treating physician,
may sign this form, revoke consent to, or request
changes to the POST orders (except in section A
as noted above) to continue carrying out the
patient’s own preferences in light of changes in
the patient’s condition.
•
Revoking/Changing POST

The voided POST form shall be placed in the
Advance Directives section of the thinned
chart.
When Not To Complete A POST Form
 A POST form should not be completed if the patient
requests contradictory orders.

One of the most likely examples: the patient wants
CPR in Section A, but wants only limited additional
interventions in Section B. The performance of CPR
requires full treatment. If the patient does not want full
treatment, including intubation and mechanical
ventilation in an ICU, then the patient should not
receive CPR.
Questions???
If you can do the Medicare CoP’s,
you can do anything!
Hospice Readiness
Hospice Readiness
 Develop a policy and procedure for POST (a sample
is available from the PCPRV or Karen or Missy.


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Establish way for staff to alert each other to patient’s
POST form and to be aware of patient preferences.
Develop method for reviewing POST form upon
admission and as patient’s condition or preferences
change. Will need to designate method for
photocopying and storing in record.
Develop procedure for ensuring that POST form is
transferred with patient from one healthcare setting to
another.
Hospice Readiness
 Ensure training for staff who missed this inservice


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and provide orientation to POST for new staff.
See that adequate number of hospice staff become
trained Advance Care Planning Facilitators
(Respecting Choices training to be offered again in
Roanoke in 12/09) so that your hospice can initiate
POST on behalf of eligible patients.
Acquire forms and envelopes through PCPRV, as
needed, for use by trained facilitators.
Designate staff representative to become involved in
pilot program through PCPRV and to offer/receive
feedback as this program evolves.
Periodically remind staff of POST and your
procedures.
POST Resources
 Palliative Care Partnership of the Roanoke
Valley


www.pcprv.org
Contact Person for POST: Laura Pole,
[email protected]
 Respecting Choices
 www.respectingchoices.org
 See list of attached area professionals who are
certified as Trainers and/or Facilitators in Advance
Care Planning
Remember:
Pilot Program Begins On
9/01/09
Thank You For Your Time & Help
In Bringing POST To Hospice Patients!
Missy & Karen
& The Palliative Care Partnership of the Roanoke
Valley