Transcript Introduction - National POLST Paradigm

Fine Tuning the POST System:
The Case of an Invalid, Contradictory POST Form
Alvin H. Moss, MD, FACP, FAAHPM
Center for Health Ethics and Law
Objectives
At the conclusion of this conference, participants should be
able to:
 Analyze a case which highlights the importance of POST
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form completion
Describe the most recent evidence on the impact of
advance directives in the country
Identify the advantages of the POST system over advance
directives to honor patients’ end-of-life care wishes
Explain how the WV e-Directive Registry will enable
patients’ end-of-life care wishes to be respected
Discuss common errors on forms submitted to the Registry
Fine Tuning the POST System:
The Case of an Invalid, Contradictory POST Form
A 78 year-old woman was admitted from a nursing home with chest
pain. She had a past history of coronary artery disease status post stent
placement, congestive heart failure, hypertension, lipid disorder, and
mild dementia. A POST form accompanied the patient and indicated
CPR in Section A and Limited Additional Interventions in Section B.
The EMTs and later the attending physician wondered what he should do
with the POST form because Section A and Section B seemed to be
contradictory. The POST form had been prepared by a social worker
who had signed it, but there was no physician signature on it.
In transporting the patient, EMS worried, “What do I do if she codes
and I do CPR and get her back, but she is not breathing normally? Do I
intubate her?” The emergency department physician wondered the same
thing, but fortunately she did not suffer a cardiac arrest during transport
The attending physician saw the patient in the emergency
department and reviewed the POST form without any additional notes
or documentation.
Fine Tuning the POST System:
The Case of an Invalid, Contradictory POST Form cont’d
When interviewed by the palliative care team who was consulted to
address the POST form inconsistency, the patient indicated that she
would not want to be kept alive on machines and when it was explained to
her that if she had CPR and lived through it, it was very likely that she
would end up being on a breathing machine. She said, “Well then, I don’t
want CPR.” A revised POST form was created and signed by the patient
and the palliative care physician. The patient was discharged back to the
nursing home.
The daughter who lived out of state and who was the patient’s
Medical Power of Attorney representative reviewed the POST form and
stated she wanted her mother to have CPR.
What should be done with regard to the contradictory POST form
and the daughter’s request? How could these situations be prevented in
the future?
Learning Issues
 Who should be making the decisions for this
patient and on what basis?
 How should that person legally be designated?
 How should the POST form be completed and
what should be indicated in each section?
 What should be done with the POST form after it
is completed?
 How could the conflict in this case have been
prevented?
Latest Studies
THE OUTCOMES OF
ADVANCE CARE PLANNING (ACP)
•The vast majority (⅔ to over ¾) of older adults are willing to
participate in ACP
•ACP results in statistically significantly different and
improved EOLC for patients
Silveira MJ et al. Advance directives and outcomes of surrogate decision
making before death. N Engl J Med 2010;362:1211-1218.
Detering KM et al. The impact of advance care planning on end-of-life care in
elderly patients: randomised controlled trial. BMJ 2010;340:c1345.
doi:10.1136/bmj.c1345
Outcomes of Advance Directives
 Of 3746 older adults (>60 yo), 42.5% required EOL decision

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making
Of these 1,536 older patients who required EOLC decisions,
70.3% lacked capacity
In short, 29.8% of older adults required EOL decisions but
lacked capacity
Of these 999 patients, 67.5% had advance directives
Patients with an advance directive were significantly more
likely to want limited or comfort care and receive it
Silveira MJ et al. Advance directives and outcomes of surrogate decision making
before death. N Engl J Med 2010;362:1211-1218.
Elements of the
Advance Care Planning Process
 Begins by clarifying the patient’s current health
status
 Moves to elicitation of the patient’s goals of care
 Identifies the patient’s preferred decision-maker if
the patient loses decision-making capacity
 Completes a Physician Orders for Scope of
Treatment (POST) form to ensure patient’s wishes
are respected
Gillick MR. Reversing the code status of advance directives?
N Engl J Med 2010;362:1239-1240.
Differences between POST
and Advance Directives
Characteristics
POST
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 (POST)
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, Kemp M. The POLST: An improvement over traditional
advance directives. Cleveland Clinic Journal of Medicine. In press.
Hickman, SE, et al. A Comparison of Methods to Communicate Treatment Preferences in
Nursing Facilities: Traditional Practices Versus the Physician Orders for Life-Sustaining
Treatment Program. JAGS. 2010; 58: 1241-1248.
Hickman, SE et al. The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on
the Physician Orders for Life-Sustaining Treatment Form. JAGS. Published online: 22 Oct 2011
Elements essential to reliable, high-quality care for patients
with fatal chronic illness—a systems approach
Lynn, J. et. al. Ann Intern Med 2003;138:812-818
COMMUNICATION
ACROSS SETTINGS
“…the health care 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.”
Code of West Virginia, §16-30-1 et seq.
Components of the System
 Standardized practices and policies
 Trained advance care planning facilitators
 Timely discussions prompted by prognosis
 Clear, specific language on an actionable form
 Bright form easily found among paperwork
 Orders honored throughout the system
 QI activities for continual refinement
 Statewide registry so that forms are available
Legal Protection with POST Use
 Standardized form according to state law
 Legally recognized DNR identification
 Protection from civil or criminal liability for
good faith compliance with and reliance upon
POST
 Protocol for use in interinstitutional transfers
 Law covers compliance with POST when
completed by MD not credentialed in facility
Transfer of POST Form
 Copier to the Photo/Picture setting
 Contrast to the lowest setting
 Double-sided copies on 8 ½ x 11” Astrobrights
Pulsar Pink 24 lb. paper*
 Adjust the contrast setting on your copier to
achieve the clearest possible copy
 Can copy white FAX onto pink paper
*Office Depot, Office Max, Staples
FORM SHALL ALWAYS ACCOMPANY
PATIENT/RESIDENT WHEN TRANSFERRED
OR DISCHARGED!
On the top of the transfer packet!
The “surprise” Question:
A Trigger
for Palliative Care Evaluation and
Advance Care Planning
“Would I be surprised if this
patient died in the next year?”
Moss et al. Utility of the “surprise” question to identify dialysis patients
with high mortality. Clin J Am Soc Nephrol 2008;3:1379-1384.
Moss et al. Prognostic significance of the “surprise” question in cancer patients.
J Palliat Med 2010;13:837-840
 Accurate, relevant information available in a medical crisis
 24/7 online access by health care providers through WVHIN
 Consumer able to confirm online accuracy of their advance
directives and medical orders (DNR and POST forms) in the
Registry
 Patients’ wishes will be respected throughout the continuum of
health care settings
 Password-protected – HIPAA compliant
Registry FAX
304-293-7442
Total Registry Forms Received by Type
Problems with POST Completion
Form Type
Error Rate
POST Forms
29%
Surrogate Selection
27%
Living Will
23%
DNR Cards
22%
Medical Power of Attorney
15%
Combined Living Will and Medical Power of Attorney
14%
 Just 4 errors make up 72% of all the “not Registry
ready” POST forms.
The Most Common POST Form Errors
The Opt-In Box was not initialed
2. The form is missing pages
3. Conflicting elections in sections A and B
4. Physician’s signature is missing
1.
Take-home Messages
 Be sure to initiate advance care planning
discussions with patients for whom you would not
be surprised if they died in the next year
 Complete POST forms as part of advance care
planning
 Submit forms to e-Directive Registry so that
patient’s medical orders will be available in a crisis
Contact the Center for…
● DNR Cards ● POST Forms ●Brochures
•Advance Directives ● Health Care Surrogate Forms
www.wvendoflife.org
877.209.8086
FAX 304.293.7442