Transcript 1 – A Review AD

A Review
Advance Directives and POLST
6/30/14
Objective
• To Review Highlights of Advance Directives
and POLST
• Describe rationale for and use of each document
• Discuss differences between advance directives and
POLST
• Define who can be a Pennsylvania Health Care DecisionMaker
1
Key Points
• What are the differences between advance directives
and POLST
• What are the differences in the powers of a health care
agent and a representative
• POLST does not replace an advance directive
• If the choice in Section A of the POLST is for CPR, the
choice is Section B, Medical Interventions, needs to be
Full Treatment
2
Advance Directives
A written statement of a person's wishes regarding
medical treatment, often including a living will, made
to ensure those wishes are carried out should the
person be unable to communicate them to a doctor.
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Advance Directive Recommendation
• Anyone may face a sudden and unexpected acute illness or
injury with the risk of becoming incapacitated and unable to
make medical decisions
• Everyone age 18 and older should be encouraged to
complete a Health Care Power of Attorney document and to
engage in advance care planning discussions with family and
loved ones
• An ongoing conversation over the years with your healthcare
decision-maker, family, and healthcare provider is very
important
4
Advance Directives
• PA Act 169 provides for health care decisions to be
made for an adult patient through three means:
1. A living will (LW)
2. A health care agent appointed by the patient (HCPOA)
3. A close family member or another to serve as a health
care representative for the patient
• Usually LW and HCPOA are combined in single
document
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Advance Directives
• Who can make a directive?
– Adult
○
○
○
○
18 years of age or older
Graduated from high school
Married, or
Emancipated
– Sound mind
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Living Wills
• A written statement of the patient’s personal
choices regarding life-sustaining treatment and
other end of life care
• Becomes effective when a patient is incompetent
and has an end stage medical condition or is
permanently unconscious
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Health Care Power of Attorney
• A written document in which a person appoints
another to serve as his agent and to make health
care decisions
• States when and what decisions an agent may make
• States patient’s preferences and values to guide
decision-making
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Advance Directive Examples
www.acba.org/Public/index.asp
www.agingwithdignity.org/
www.upmc.com/advancedirective
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Online Example – Useful Tool for Public
Slides walk you through the process and the user can listen
to instructions.
www.prepareforyourcare.org
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10
Above slide shows the five different areas that are covered.
It all does not need to be done at one time.
1
1
Advance Directive Triggering Event
• Patient is in a state of:
– Incompetency
– End stage medical condition
– Permanently unconscious
*In the Pennsylvania statute, “incompetency” is the
term that is used. In practice, the term in often used
interchangeably with “lacking capacity”.
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Capacity
• Assessment of Capacity
– Not always constant or fixed
– Not always absolute either/or
– Capable for some decisions/not all
• Elements of capacity
– Ability to understand situation and that there is a
decision to be made
– Able to communicate preference
– Able to make a judgment/choice
– Able to give rational reason for choice
13
Decision-makers
• Health care agents
– Designated in a health care power of attorney
– Authority is usually limited to when patient is
incompetent/not lacking capacity
– Not restricted to end-of-life decision-making
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Decision-makers
• Health care representatives may make
health care decisions for an incompetent
patient/lacking capacity who has:
– No health care agent (or no reasonably
available agent)
– No legal guardian of the person
15
Decision-makers
• Health care representatives
– May be designated by patient. For example, during the
admission process, an adult patient may designate his
representative should he become incompetent during
his hospital stay
– If not designated, selected from priority list in law
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Decision-makers
If no agent appointed, the law gives priority
in this order:
1. Current spouse and adult child of another
relationship
2. Adult child
3. Parent
4. Adult sibling
5. Adult grandchild
6. Close friend
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This is page one of a document that defines the various power of health care
decisions makers. Full document found at POLST website,
http://www.aging.pitt.edu/professionals/resources-polst.htm
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Who is the
Pennsylvania Decision-Maker
Quick Start Guide Health Care Decision-Making*
If the patient is unable to engage in the POLST discussion, it is critical that the conversation
occurs with the correct legal decision-maker
–
–
–
–
–
•Power to Sign POLST or Agree to DNR
Competent Patient - Yes
Health Care Agent - Yes
Guardian - Yes, but..
Health Care Representative - Yes, but…
Incompetent Patient – No
*Copyright 2012 Robert B. Wolf, Esquire
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Who is the
Pennsylvania Decision-Maker
Quick Start Guide Health Care Decision-Making*
–
–
–
–
•Power to Revoke a POLST or DNR Order
Competent Patient – Yes
Health Care Agent - Yes if signed by Agent - Otherwise maybe
Guardian - Yes, if signed by Guardian
Health Care Representative -Yes, if signed by Health Care Representative
*Copyright 2012 Robert B. Wolf, Esquire
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Who is the
Pennsylvania Decision-Maker
Quick Start Guide Health Care Decision-Making*
–
–
–
–
–
•Power to Decline Care Needed to Preserve Life
Competent Patient – Yes
Health Care Agent – Yes
Guardian – Yes, if End State Medical Condition (ESMC) or Permanently
Unconscious (PU)
Health Care Representative - Yes, if ESMC or PU
Incompetent Patient - No
*Copyright 2012 Robert B. Wolf, Esquire
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POLST
POLST is designed to honor the freedom of persons
with advanced illness or frailty to have
or to limit treatment across settings of care.
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What is POLST
• POLST is a voluntary process that:
– Translates a patient’s goals for care at the end of life into medical
orders that follow the patient across care settings
– Consists of medical orders that are based on a patient's medical
condition and his/her treatment choices as established in
communication between the patient or the legal medical decisionmaker and a health care professional
– Allows health care providers to know a patient’s wishes in the event
of a serious illness and to honor them
• In some institutions, the POLST document is used to
establish goals of care for all patients
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POLST and Advance Directives
• The POLST is not intended to replace an advance health care
directive document or other medical orders
• The POLST process and health care decision-making works
best when a person has appointed a health care agent to
speak for them if they become unable to speak for themselves
• A health care agent can only be appointed through a health
care power of attorney
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Who Would Benefit from a POLST
• There are no age specifications. Anyone with
–
–
–
–
Advanced illness
A serious health condition
Medical frailty
Advanced age and wishing to further define their
preferences for care
• Tool for determination
– Ask yourself “would I be surprised if this patient died
within the next year”.
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POLST Form Highlights
• Physician, physician assistant or CRNP medical order
• Standardized form, bright distinct color
• Based on conversation for goals of care
• May be used to limit medical interventions or clarify a request
for all medically indicated treatments including resuscitation
• Transferrable across care settings
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POLST, Who Fills it Out?
•
Physician or physician designee facilitator (RN, NP,
PA, Social Worker)
•
Facilitators need to be skilled, knowledgeable and
credible to physicians/providers as well as
patients and families
•
Verbal orders are acceptable with follow-up
signature in Pennsylvania in accordance with
facility/community policy
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Requirements to Make the Form Valid
• Patient name (date of birth recommended)
• Completion of Section A, resuscitation orders
• Physician/PA/CRNP signature*
• Patient or surrogate signature
• All other information is optional
*In Pennsylvania, a physician assistant signature requires a physician
co-signature within ten days.
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Differences between
POLST and Advance Directive
Characteristics
POLST
Advance Directive
Population
For the seriously ill
All adults
Timeframe
Current care
Future care
Who completes the form
Health Care Professionals
Patients
Resulting form
Medical Orders (POLST)
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
Above table based on:
Sabatino, Charles; Karp, Naomi, AARP Public Policy Institute, (2011) “Improving Advance Illness
Care: The Evolution of State POLST Programs”, http://assets.aarp.org/rgcenter/ppi/consprot/POLST-Report-04-11.pdf, p4.
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Where Does POLST Fit In?
Advance Care Planning Continuum
Age 18
Complete an Advance Directive
Update Advance Directive Periodically
Diagnosed with Advanced Illness or a
Serious Health Condition (at any age) or
Medical Frailty*
Complete a POLST Form
Treatment Wishes Honored
Materials adapted and used with permission from the Coalition for
Compassionate Care of California, www.coalitionCCC.org
*Someone for whom you would not be
surprised if they died within a year
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HIPAA
Compliant
Cardiopulmonary
clarifies type of
resuscitation. Do
Not Attempt
Resuscitation
assists clinicians
in communicating
odds about
success
Options
give people
the choice
to decide
later since
issue of
when to use
antibiotics
is complex
Discussion
about
treatment
preferences
is required
Pennsylvania Form
Clear
instruction on
when to
transfer to
hospital and
use of
intensive care
IV fluids in
Limited
Additional
Interventions
section
Artificial
hydration and
artificial
nutrition both
found here
If any section
left unmarked,
the highest
level of
treatment must
be provided
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Section A
Cardiopulmonary Resuscitation
• In choosing CPR or DNR, patients need understanding of the
benefits/burdens
• Television portrayal of CPR unrealistic with 66% surviving. In real life for
elderly patients
• 22% may survive initial resuscitation
• 10-17% may survive to discharge, most with impaired function
• Chronic illness, more than age, determines prognosis in the elderly
– With chronic illness, average survival rate less than 5%.
– With advanced illness, survival rates are often less than 1%
•
•
•
•
Annals Int Med 1989; 111:199-205;
NEJM.1996; 334(24):1578-82.
JAMA 1990; 264:2109-2110
FAST FACTS AND CONCEPTS # 024 and #179
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Section A
CPR and Medical Interventions
• If choosing “Attempt Resuscitation / CPR” in Section A, “Full
Treatment” is required for Section B, Medical Interventions
• It is not appropriate to request “Attempt CPR” and “Comfort
Measures Only”
• If a person wants CPR, they must be willing to have ACLS
(Advanced Cardiac Life Support) guidelines followed, which
usually includes intubation and care in the ICU
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Section A
DNR and Medical Interventions
• “Do Not Attempt Resuscitation / DNR” may be chosen with
any of the medical interventions in Section B
• “DNR” with “Full Treatment”
– Can choose to receive aggressive medical interventions, but
doesn’t want to be resuscitated if found without a pulse or not
breathing (they have died)
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Diagram of POLST Medical Interventions
CPR
DNR
Comfort Measures
Limited Interventions
Full Treatment*
*Consider time/prognosis factors under “Full Treatment”
“Defined trial period. Do not keep on prolonged life support.”
Materials adapted and used with permission from the
Coalition for Compassionate Care of California,
www.coalitionCCC.org
35
POLST and EMS
At top of form it states:
To follow these orders, an EMS provider
must have an order from his/her medical
command physician.
36
Out-of-Hospital DNR
EMS providers may only follow a PA OOH-DNR
order, bracelet, or necklace.
or
Orders from a medical command physician
37
The standardized POLST allows for faster and
more efficient discussion between EMS and the
medical command physician.
38
Pennsylvania Form 2nd Side
This side includes:
Surrogate Contact
Information
A line for the
signature of a POLST
Facilitator who
completes the form
Currently, the POLST form is not available
on the Pennsylvania Department of Health
website. It is found at:
www.aging.pitt.edu/professionals/resources.htm
39
Revocation of POLST Form
• May be revoked by patient at any time
• If patient lacks decision-making capacity, a legal
decision-maker may revoke
• Revocation can be a verbal statement
• Draw a line through sections A through E of the invalid
POLST
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Transfer
•
Original pink form
–
–
−
Transferred with individual (Use of original form is highly
encouraged)
Photocopies and Faxes of signed POLST forms are valid
It is recommended that copies be made on pulsar pink paper
• Health care institutions
–
–
Keep duplicate copy in permanent medical record upon
discharge
Also make copy prior to inter-facility transports
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Key Take Away Points
• What are the differences between advance directives
and POLST
• What are the differences in the powers of a health care
agent and a representative
• POLST does not replace an advance directive
• If the choice in Section A of the POLST is for CPR, the
choice is Section B, Medical Interventions, needs to be
Full Treatment
42
Acknowledgment
We would like to recognize the
Pennsylvania Medical Society
for use of materials from:
“A Guide to Act 169 for Physicians
and Other Providers”
43