Transcript Slide 1

POLST
INTRO TO ILLINOIS’S NEW IDPH UNIFORM
Physician Orders for
Life-Sustaining Treatment
DNR ADVANCE DIRECTIVE
Presented for Long Term Care
by:
Meet Hobart
• Hobart is 87 years-old and went
to live in a nursing home after his
wife died three years ago.
• He just got back from the
hospital where he was admitted
for four days and treated for a
serious infection
• He tells you how much he hates
going to the hospital and he
doesn’t want to do that again
Hobart’s Rights
• Hobart has the right to say what
care he wants, and also what
medical treatments he doesn’t
want
• As a caregiver, you want to make
sure that he gets every medical
treatment he wants, but also
that he is not forced to receive
treatments he does not want
Making Good Plans for Hobart
• Hobart’s daughter knows his
wishes, but his daughter lives in
another city and works a very
busy job.
• Sometimes Hobart’s daughter
doesn’t immediately answer
her cell phone, even though
she always returns your calls at
some point
Making Good Plans for Hobart
• You know that sometimes
residents can get sick fast.
• Hobart may develop another
infection, or it can be an
emergency like a heart attack
or the inability to breathe on
his own
• How do we make plans to
guide us in an emergency?
What Options Do You Have?
• The first step many people take
when they want to make sure
their wishes about medical
treatment are honored even
when they can’t make their own
decisions is an Advance Directive
• The most common Advance
Directive is a Power of Attorney
for HealthCare
A Power of Attorney (PoA) is a Person
Who Can Make Medical Decisions
• The Power of Attorney for
Healthcare tells you who should
make medical decisions for Hobart
if he can’t make those decisions
for himself
• This is a good option, but his
daughter has to be contacted by
phone, and during an emergency
like a heart attack, every second
counts
• Is there something that addresses
emergency medical treatment?
POLST
• A good Advance Directive
that can tell you what
Hobart wants in an
emergency is an Advance
Directive called POLST
• POLST stands for Physician
Orders for Life Sustaining
Treatment
POLST for Hobart
• POLST tells everyone taking care of Hobart
what his wishes are in case of a lifethreatening emergency
• The use of the POLST form is consistent with
CMS regulations
Hobart’s Wishes During an Emergency
• Hobart tells his doctor that he
wants to be treated for
infections and pain, but if his
condition is so serious that he
needs life-support, he does not
want that.
• He would rather stay at the
nursing home and just be
made comfortable.
POLST Provides Medical Orders
• Now we have to find out
which POLST options best
fit Hobart’s wishes
• POLST has five sections,
but you probably only
need to know about two
of those sections
The POLST Document
• 2 Emergency Medical Order Sections
A. CPR for Full Arrest
• Yes, Attempt CPR
• No, Do Not Attempt CPR (DNR)
B. Orders for Pre-Arrest Emergency
• Full Treatment
• Limited Treatment
• Comfort Only
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Section A and Section B
• Section A: should you do
CPR if the resident stops
breathing and has no pulse?
• Section B: how aggressive
should the treatment be if
the resident has a lifethreatening emergency but
is still breathing?
Relieve Suffering Always
• It does not matter what
options a resident chooses
– he or she should always
be medically evaluated and
provided with pain relief
and relief of any suffering
• Other wishes, like calling
family members or a clergy
person should also be
followed
Section “A”: Cardio-Pulmonary Resuscitation
Code Status – applies when breathing AND pulse have stopped
• If the person chooses “Attempt Resuscitation” you do
NOT need to look at any other box on this form. Start
CPR and “Go.”
• If the person checks “DNR” and is in full arrest, “Stop”
and do not begin CPR.
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Section A: Full Cardiac Arrest
• There are 2 options in Section A
– Yes, please try CPR to resuscitate me
– No, if you find that I have died,
please do not try to bring me back
• If Hobart chooses CPR it may or
may not work, but we will try
everything, including calling 911
• If Hobart chooses no CPR, his body
will be treated with dignity and his
family will be called
Would Hobart Choose
CPR?
• Hobart accepts that he is
coming to the end of his life.
• He says to his doctor “if it is
my time to go, I don’t want
you to try to bring me back.
Just let me go.”
• Hobart would choose DNR
for full arrest.
Section B: Emergencies when the
resident is still alive
• The next section, Section B,
talks about emergencies like a
heart attack or difficulty
breathing where the resident
is still alive but is in danger of
dying if immediate action
isn’t taken
Section “B”: Medical Interventions
Do Not Resuscitate does NOT mean Do Nothing
• If the patient is still breathing or has a pulse, how aggressive should our
treatments be?
• Comfort – patient prefers to stay at the facility and be made comfortable,
• Limited – patient wants basic treatments but not life-support
• Full – patient wants everything done
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Section “B”: Medical Interventions
• If the resident chooses the first category of comfort only, in red, you should consider
what you can do to make them as comfortable as possible in their own bed. Comfort
treatment is still treatment, you just try to do maximize the care the person receives
without sending them to the hospital.
• Talk to the nursing supervisor or the patient’s doctor to get them the care they need.
• If the person has care needs that can not be met in their own bed, you may still need
to send them to the hospital. The relief of any pain and suffering is your highest goal.
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Section “B”: Medical Interventions
• If the resident chooses Limited treatment, in yellow, you should still move
quickly to get them the care the need, but you need to proceed with caution
because the patient has said there are some treatments they do not want.
• You can think of this section like a stoplight. If the resident chooses the last
category of full treatment, in green, you should quickly “go” and get them all the
care they need, including going to the hospital.
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Would Hobart Choose
Comfort Only?
• The option of Comfort Only
on the POLST form in Section
B is for those residents who,
at the end of their life, do
not want any more hospital
medical care and just want
to be made as comfortable
as possible in their own bed
• This does not sound like
what Hobart wants
Limited Treatment – Still Treatment,
But Does Not Include Life-Support
• The second option in Section B is
Limited Treatment.
• This option says that the resident
wants to be treated for medical
problems, but doesn’t want to be
put on life-support, even if it is
needed to keep him from dying
• This sounds like the option Hobart
would want to choose. He will still
go to the hospital, but he will not
have to be on life-support
Would Hobart Choose
Full Treatment?
• The last option under Section B is
“Full Treatment” which includes
life-support (that is why it says
Intubation and Mechanical
Ventilation which involves a
machine to help him breathe).
• If he chooses “Full Treatment” he
will be put on life-support if he
needs it.
• At any time, Hobart can change his
mind and ask for all medical
treatments that can be offered.
Section C: Feeding Tubes
• The next section, Section C, is really for doctors.
• It tells healthcare providers if the resident wants
an artificial feeding tube to provide nutrition if the
resident is not able to eat enough food by mouth.
• Often times, a person who is in the final stage of
life can no longer process the nutrition, or they
may not want a feeding tube.
Food by Mouth
• Residents should always be offered
food by mouth as they desire or as
is medically feasible.
• Careful hand-feeding has been
shown to be as effective as feeding
tubes for some residents at the
end-of-life.
• If a resident has chosen DNRComfort, staff may want to
consider offering the resident the
food of the resident’s choice.
What Should I Do With The POLST?
• It is important that the POLST
document be immediately available
during an emergency where every
second counts
• Your institution should decide on an
easy to find location that is the same
for every resident
• You also want to choose a location
that still protects the resident’s
privacy regarding their healthcare
choices
Does the Color of the Form Matter?
• NO.
• It is recommended that the form
be printed on pink paper – this is
only to make it easier to see
• The original pink form should stay
with the resident at all times,
especially when they transfer
• However, all copies of the form are
valid, regardless of color
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Requirements to Make the Form Valid
3 Signatures are Required
• Patient/Resident name
• Resuscitation orders (Section “A”)
• Signatures
– Patient/Resident or Legal Representative signature
– Witness signature
– Provider signature, name, and date (this makes it
medical order that has to be followed by everyone)
• All other information is optional
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This presentation for the POLST Illinois Taskforce has
been made possible by in-kind and other resources
provided by:
THANK YOU!
Original presentation developed
by Kelly Armstrong, PhD
for the Illinois POLST Taskforce.
Contact: [email protected]