Transcript Introduction to IPOST *Iowa Physician Orders for Scope of Treatment*

Introduction to IPOST
“Iowa Physician Orders for
Scope of Treatment”
Francis Dominic Degnin M.P.M., Ph.D.
Associate Professor, UNI
Department of Philosophy & World Religions
Clinical Ethicist
Wheaton Franciscan Health Care of Iowa
The State of Iowa IPOLST Web page
http://www.idph.state.ia.us/IPOST/Defaul
t.aspx
Many slides come directly from this site.
Primary Resource

Originally part of the POLST (Physician
Orders for Life Sustaining Treatment)
project, IPOLST was first piloted in in
Iowa in 2008. It was signed into Law and
took effect statewide on July 1st, 2012.

POLST forms are used, either in pilot or
final form, in over half the states.
History
General:
Like all advanced directives, IPOLST is intended to help
ensure that patient’s health care wishes are honored.
Specific:
IPOLST attempts to provide actionable details for EMTs and
ERs in emergency situations.
IPOLST attempts to address an identified problem that
many providers use resuscitation status to entirely
determine the level of treatment—either comfort measures
or full code. IPOSLT allows patients a greater range of
treatments between these two extremes.
Purpose

1-page, 2-sided form based on the national POLST movement
that consolidates and summarizes patient preferences for key lifesustaining treatments including: CPR, general scope of treatment,
artificial nutrition on a standardized, clearly identifiable form.

IPOST complements advance directives by translating patient
treatment choices into actionable medical orders which can be
relied upon across all care settings.

It is primarily intended to be used by:
• the chronically, seriously ill individual in frequent contact with
health
care providers
• an individual with a life-limiting illness
• the frail and elderly
(Palliative Care PP 16)
What is IPOLST?

Are one page, two sided, salmon colored.

Cannot be reproduced or modified by health care
institutions.
◦ Patients can include additional instructions.

Can be copied once filled out. A copy or a fax is
equally valid, even if on standard paper.

Changes made to an existing IPOLST require a
new form.
IPOLST Forms

IPOST at front of patient’s medical chart

IPOST transfers with patient from one healthcare setting to another including
to and from home

Update or void IPOST when the patient’s treatment choices change or
substantial change in person’s health status

Regular review of IPOST at quarterly care conferences in facilities or physician
appointments

Data collection to determine implementation rate and effectiveness
IPOST belongs to the patient
(Pal Care PP 21)
Operations and Evaluation
IPOLST may replace a Living Will, but it should not a
Durable Power of Attorney for Health Care.
If there is a conflict between IPOLST and the two
more traditional advanced directives, Iowa Law
specifies that IPOLST is secondary.
?
This may be a meaningless distinction, because the
real issue is to get at the patient’s wishes, not to
blindly follow a set of rules. If it becomes clear to us
that IPOLST better expresses a patient’s wishes, the
Cruzan 1990 would trump state law.
IPOLST and other Advanced
Directives?

The provider fills out the form in conversation with the
patient or surrogate.
◦ The state offers training on these provider-patient discussions.

The Patient or Surrogate must sign the form.

One of the following must also print, date, and sign:
Physician
Nurse Practitioner
Physician’s Assistant

A phone in order is acceptable so long as it is later signed
by the provider.
Filling out IPOLST

Any section not filled out implies full treatment in that
section.

A semi-automatic external defibrillator should not be
used for a DNR patient unless otherwise specified.

Allows for deactivation of an internal defibrillator if
comfort only measures are in effect.

Comfort medications by alternative routes or
administration are compatible with comfort only
measures.
(IPOST Form pg 2)
Using IPOLST

Draw a line through sections A-C and write VIOD
over these sections. Sign and date.

Fill out a new IPOSLT if appropriate.

If released to a care facility, return both the old
and the new forms with the patient. The care
facility will destroy the old form.

If released home, the hospital destroys the old
form and sends the new form home with the
patient.
Revoking an IPOSLT Form (In
hospital)

Converts patient preferences into immediately actionable medical orders readily
accessible to medical personnel, including EMTs

IPOST alters treatment: The presence of the IPOST changed the treatment that the
healthcare provider would have given if patient did not have IPOST Treatment
changes included: comfort measures only, type of resuscitation, no intubation and
no intravenous line started

IPOST addresses a misconception: Healthcare providers are often under the
assumption that patients either want the maximum or minimum level of care across
all end-of-life treatment options. Our medical chart review and several studies have
shown that the majority of patients want different levels of end-of-life treatment

IPOST addresses this misconception by documenting the type of treatments the
patient wants regarding resuscitation, medical intervention and nutrition

Positive staff, facilitator and patient/family experiences
(Overview PP 12)
IPOST Strengths
(identified by evaluation)
Was treatment altered to respect patient choices based on
having an IPOST available?

28% (n=16) surveyed indicated IPOST form altered treatment

Most frequent treatment altered was Comfort Measures Only.
• 33% indicated treatment would have been more aggressive without
IPOST

Second most frequent treatment altered was Type of Resuscitation.
• 22% indicated CPR/Attempted Resuscitation was reevaluated due to
presence of IPOST

No Intubation (19%), No Intravenous Line started (15%), and Increased Level
of Treatment (11%) were also indicated by those surveyed that these
treatments were altered based on the IPOST
(Palliative Care PP 24)
Healthcare Provider Survey
What do healthcare providers think about IPOST?

90% wished more patients in the area had IPOST forms,
the other 10% were neutral

92% agreed that the IPOST form provides clear
instructions about patient’s preferences

87% feel more comfortable knowing what to do when an
IPOST form is available

80% agreed that the IPOST form has made more difficult
decisions easier
(Pal Care PP 24)
Healthcare Provider Survey