Transcript Document

You’ve Got
Questions?
Sally Hardwick, MS
We’ve Got
Answers
Chair, Nevada POLST – A Nevada Non-Profit
Providers Training
In the Beginning
• POLST: Physician’s Order for Life-Sustaining
Treatment
• Oregon POLST – 1991
• Advance Directives (ADs) provided general
guidelines, but specifics were still vague
• ADs are difficult to locate
• Too long
The Oregon POLST
• Meaningful Conversation of patient wishes and
treatment ramifications
• Succinctly identifies patient wishes
• Easily identifiable
• More specific treatments
• Portable medical orders
• Intended redundancy
Similarity to ADs
• Thoughtful, considered
conversation with
patient and loved ones
• Based on values
• Comfort measures are
always provided
• Only used when unable
to express themselves
Differences between the
Nevada POLST Program
and Other ADs
•
This is not just a form, it is a program involving a discussion between providers
and patients and coordination between facilities and emergency medical
services
•
Frail, elderly or those with serious, advanced, progressive disease
•
5 year life expectancy
•
Reflects current state of health
•
Medical order that travels with the patient (home, transport or facility)
•
Requires physician and patient or patient’s representative’s signature and date
•
Provides for an out-of-hospital DNR (residence, transporting) honored by
Emergency Medical Services (EMS)
•
Should indicate with whom discussed as well
•
Concise
Features: Recognizable
• Nevada POLST forms are bright pink
• Available at:
• Order at: www.NevadaPolst.org
• Download for Educational Purposes:
• Nevada State EMS:
http://health.nv.gov/PDFs/EMS/Forms/POLSTf
orm.pdf or,
• www.NevadaPolst.org (with watermark:
“SAMPLE”)
Features: Portable
Patient
POLST
EMS
ASK
Facility
POLST Side One: Medical
Orders
•
•
•
•
•
Instructions
Patient Information
Section A: CPR
Section B: Other medical interventions
Section C: Physician documentation
POLST Side One: Medical Orders
Instructions / Patient Information
• Write the date in the date of birth box:
Ex: Feb. 12 1941
POLST Side One: Medical
Orders
Section A: CPR
• EMS-DNR #: from the salmon colored card
• No longer necessary; legislature approved POLST to be
honored in all settings
• The salmon colored card is no longer necessary unless
someone wants it for use when away from their
residence.
• POLST must be signed and dated by a physician in
Section C and the patient or their agent in Section F
POLST Side One: Medical Orders
Section B: Interventions:
Comfort Measures
• Relevant if:
• “Allow Natural Death” marked in Section A or
• Patient is not in cardiopulmonary arrest
• If checked, patient should remain at current location
(home, nursing home, etc.), unless comfort cannot
be achieved at this location
POLST Side One: Medical Orders
Section B: Limited Medical Interventions
• Remind patient the POLST is ONLY used if they
are so sick they can’t speak for themselves.
• Explain the implications, what it may involve and how it may
affect them.
• Beware of conflicting orders.
POLST Side One: Medical Orders
Section B: Interventions:
Full Treatment
• Explain the implications. Explain that treatment
may or may not be successful, and may result in
additional discomfort.
• Discuss “Additional Instructions” - might include a
trial period of treatments to determine tolerance and
benefit.
POLST Side One: Medical Orders
Section C: Physician Validation
• REQUIRED for validity
• Signature
• Date
• Other boxes
• Very helpful should there be any question of validity
• Printing template at www.nevadapolst.org/nevada-polstform/printing-instructions/ Printing Repetitive Information
for Section C
• Transfer Reminder
POLST Side Two: Patient
Preferences
• Organ Donation
• AD Information: Summary of information in
patient’s Living Will, Declaration and/or Durable
Power Of Attorney (DPOA)
• Conversation documentation
• LivingWillLockbox.com information
• General Instructions
POLST Side Two: Patient Preferences
Section D: Organ Donation
• Name and Date of Birth – Verify with
patient bracelet
• Checking Section D box does NOT give
authorization for organ donation; check their
NV State issued ID to verify
POLST Side Two: Patient Preferences
Section E: Advance Directive Summary
• If AD available, complete this section!
• If AD is registered with the Secretary of State,
LivingWillLockbox.com, patient may have an ID
card available
• #2 – State law provides an order of authority for
resuscitation orders only.
POLST Side Two: Patient Preferences
Section F: Signatures
• Circle the responsible party with whom you
have spoken regarding the POLST
• Agent is the person specified in the patient’s Durable Power of
Attorney for Health Care (DPOA)
• Patient or their representative MUST sign and date it
• Consent with witness will reduce confusion and conflict when
POLST is needed
• Preparer may be physician (required for Side 1), nurse or social
worker
POLST Side Two: Patient Preferences
Section G: Registry
• Registry is the Secretary of State’s
LivingWillLockbox.com (LWL)
• Your facility and/or office should:
• Be registered for access to Livingwilllockbox.com
• Have a supply of authorization forms on hand
• Have a process in place to assure POLSTs and ADs are
registered
• Offer both POLST and LWL authorization form at
patient interview
• When signed, or at least explained, initial box
POLST Side Two: Patient Preferences
Section G Alternative
• The use of Health Information Exchanges (HIE)
assure patient information is available across health
care settings and between providers
• HealthInsight offers HealtHIE Nevada for this
purpose.
• ADs, POLST and other patient medical information
can be accessed on HealtHIE Nevada
• A significant number of providers, labs, pharmacies,
etc. have already begun uploading records.
• For more information:
http://www.healthienevada.org/
Reimbursement Codes
• Out-Patient Consultations
• Wellness codes
• Fewer than 10% of providers are utilizing wellness
codes.
• Provides an opportunity to review medications, past
history and end-of-life considerations
• In-Patient Consultations
• CPT II codes
• NevadaPOLST.org/billing-for-polst-consultation/
What are the Legal
Implications of POLST
• POLST is a state approved form (AB344)
• You cannot be disciplined or face legal action if:
• Treatment is withheld in compliance with the POLST
form and the medical orders reflected on it;
• The provider is unaware of the existence of a POLST;
or,
• The patient, their agent, parent or legal guardian overrides it (Any of these may over-ride a POLST form)
Physician Authority and
Priveleges
• Health care providers shall comply with a valid
POLST regardless of whether the physician who
signed the POLST:
• Has authority during transport or
• Has privileges at the receiving facility
Physician Responsibility
• A POLST should be completed for a patient
if:
• Their life expectancy is less than 5 years; and,
• They have a terminal illness or are very frail; or,
• They request one
• In these instances, the physician shall
explain:
• The availability of the POLST;
• The features and procedures offered by it; and,
• The difference between the POLST and other ADs
Reviewing and
Revising the POLST
• A POLST should be reviewed when
the patient:
• Is transferred from one care setting or level to
another;
• Has a substantial change in health status; or,
• Preferences change
• When a POLST needs to be revised due to
wear/tear or change of orders or other information
• Write VOID diagonally across both sides of the
POLST and place in the patient’s chart
• Complete a new POLST, sign and date it
Conflicting Documents
• Should an AD and POLST conflict, the most recent
one will be considered valid.
• If a patient has a POLST that directs CPR be given
to a patient with a valid DNR identification, CPR
shall not be provided if the ID is with the patient
regardless of which is more recent.
• IF A PATIENT HAS A DNR ID THAT CONFLICTS
WITH THEIR POLST, determine which treatment they
wish, then complete a POLST reflecting those orders. Ask
the patient to destroy their DNR card to avoid confusion.
Compliance with POLST
• Should a physician or other health care provider be
unwilling to comply with the directives of the
POLST, all reasonable measure shall be taken to
transfer to a compliant facility.
• If a patient is known be pregnant, so long as it is
probable that the fetus will develop to the point of
live birth with application of life-sustaining
treatment, life-sustaining measures shall be
attempted.
Blank Sections and
Other States’ POLSTs
• Any completed section is valid unless the POLST is
not signed and dated by a physician (Section C) and
the patient or the patient’s representative (Section F).
• Blank sections should be presumed to indicate full
treatment, unless it conflicts with a completed
section.
• A valid POLST (MOST, POST, MOLST) of another
state shall be honored in Nevada.
RESEARCH
Journal of the American Geriatric
Association (JAG)
• Association Between Physician Orders for LifeSustaining Treatment for Scope of Treatment and
In-Hospital Death in Oregon
• Published Online June 9, 2014 – Available soon in
June issue of JAG
• 17,902 subjects – largest study to date
RESEARCH –
POLST Preferences and Hospital
Deaths
• POLST Preferences
• Comfort Measures Only – 66.1%
• Limited Interventions – 26.7%
• Full Treatment – 6.4%
• Association between POLST Choices and Hospital
Deaths:
• Comfort Measures Only – 6.4%
• Limited Interventions – 22.4%
• Full Treatment – 44.2%
• For those without a POLST – 34.2% were
hospitalized
RESEARCH –
POLST Preferences and
Hospital Deaths
• Take Away Message
• Vastly more who complete a POLST choose CMO
• Those with POLSTs for CMO were significantly LESS
likely to die in a hospital
• Those with orders for full treatment were MORE likely
to die in the hospital than those without a POLST
• This holds for each of the top 10 causes of death.
• End-of-life preferences to avoid hospitalization as
documented in POLST orders are honored
Research
JAGS, Volume 58 Issue 7, 2010
• Stratified, random sample of 90 Medicaid-eligible nursing
facilities in Oregon, Wisconsin, and West Virginia, 1711 living
& deceased subjects.
• Residents with POLSTs were more likely to have orders
regarding life-sustaining treatment other than CPR (98.0% vs
16.1%, P<.001).
• POLST was more effective than traditional practices at limiting
life-sustaining medical interventions residents did not want
• Residents with POLST forms requesting comfort measures
only were less likely to receive medical interventions (e.g.,
hospitalization), (P=.004), than residents with traditional DNR
orders (P<.001), or residents with traditional full code orders
(P<.001).
Nevada POLST
Nevada POLST is a Nevada non-profit formed
specifically to:
• Educate and train the public and health care providers
regarding the Nevada POLST Program
• Provide state approved Nevada POLST forms…bright
pink, 65# stock
• Support other organizations in providing
compassionate end-of-life care
For more information visit www.nevadapolst.org