Transcript the POLST CME Program for Physicians, Mid

POLST:
Pennsylvania Orders for
Life-Sustaining Treatment
Respecting Wishes Across Care Settings
CME Program for Physicians, Mid Level Practitioners and Nurses
May 2014
Objectives
At the conclusion of this program, the
health care worker will be able to:
 Define POLST
 Discuss the process for implementing
POLST at St. Luke’s
 Demonstrate understanding of SLUHN
roles and expectations related to POLST
What is an Advance Directive?
 Advance Directives allow individuals to
document wishes concerning medical
treatments at the end of life
 Examples
 Health Care Power of Attorney document
 Living Will document
 A written combination of a Health Care Power of
Attorney document and a Living Will document
 Allowing patients to retain control over the
life-prolonging treatment they choose to
receive requires advance planning
Barriers to Advance Care Planning
Patient’s View:
 Very personal
 May elicit strong emotional reactions
 Conflict about who would make
decisions and how decisions can be
made
 Difficulty making decisions regarding
when medical treatment should be
continued or forgone
Health Care Professional’s View:
 Difficult conversation to have
 It may be unclear how to start
the conversation
 It may raise issues that are
difficult to resolve
 Requires time for discussion
System’s View:
 Communication
 Documents may not be available
 Instructions in documents
 May be too vague or too specific to be helpful
 Not available when needed
 Efforts to reopen the conversation are rarely made
Two Types of Advance Directives
Traditional –
 Little or no impact
on immediate
course of care
 Living will
 Durable Healthcare
Power of Attorney
Actionable –
 Direct and relatively
immediate impact on
course of care
 POLST Paradigm
 Do not resuscitate
order (DNR)
 Out-of-Hospital DNR
McAuley & Travis, Am J Hospice & Palliative Care 2003;20(5):353-359.
Advance Directives
Pennsylvania recognizes two types of
Advance Directives
Living will – describes wishes regarding medical care
if you cannot speak for yourself
 Only applies to patients with an end-stage medical
condition or are permanently unconscious and who
are incompetent
 “If-then” model when determining care
Durable Power of Attorney for Healthcare –
allows you to appoint a person to make healthcare
decisions for you in case you cannot speak for yourself
 More flexible than a living will
 Does not list specific treatment wishes
POLST
Pennsylvania (Physician)
Orders (for)
Life
Sustaining
Treatment
Purpose: To communicate a summary of a
patient’s preferences and provide medical
orders for end-of-life treatment across care
settings that is easy to interpret in an
emergency situation.
About POLST
 A medical order indicating a patient’s
wishes regarding treatments commonly
used in emergent situations
 Also helpful in guiding treatment after the
initial emergency
 The POLST form complements the
Advance Directive – it does not replace it
 An advance directive is necessary to appoint
a legal health care representative
 Does not replace in-hospital DNR form DNR form still needs to be completed
POLST is for…
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Seriously ill patients (chronic, progressive disease)
Terminally ill patients
Patients with advanced frailty
Others interested in defining their care
Unless it is the patient’s preference, use of the
POLST form is not appropriate for persons
with stable medical or functionality problems
who have many years of life expectancy.
The Rationale for POLST:
Limitations of Advance Directives
 Advance Directive may not be readily available
 Not completed by most adults
 Not transferred with patient
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May not have prompted needed discussion
May not be specific enough
No provision for care in the home/nursing home
May not address topics of most immediate need
May be overridden by a treating doctor
Does not immediately translate into a physician
order
Comparison
Advance Directive
POLST
 For anyone 18 and older
 Provides instructions for
future treatment
 Appoints a Health Care
Representative
 Does not guide
Emergency medical
Personnel
 Guides inpatient
treatment decisions
when made available
 For persons with serious
illness – at any age
 Provides medical orders
for current treatment
 Guides actions by
Emergency Medical
Personnel when made
available *exception in our region
 Guides inpatient
treatment decisions
when made available
Comparison
Advance Directive
 Not always readily
available
 Statement of
preferences may not
be specific enough
 Requires interpretation
 No provision for
treatment in the
nursing home
POLST
 Stays with patient
across care settings
 Check boxes of
preferences
 Consistent terminology
 A physician’s order to
be followed across
care settings
POLST is designed to honor the freedom of persons with advanced
illness or frailty to have or to limit treatment across settings of care
5 Key P’s of a POLST Form
 Physician (form may be completed by a physician, physician
assistant with co-signing physician or certified nurse practitioner in
PA)
 Portable (travels with patient to any point of care to assure
his/her wishes related to life sustaining treatment would not be lost in
transition)
 Preferences (turns patient’s treatment preferences and
Advance Directives into medical orders)
 Primary goal (to ensure wishes for treatment are honored)
 PINK! (nationally accepted color…exception NJ form is GREEN)
Who can complete a POLST?
In Pennsylvania…
 Physician
 Physician Assistant
 Requires physician co-signature within 10 days
 Certified Registered Nurse Practitioner
 Individual assumes full responsibility for the
medical indications of the orders and assuring
they accurately reflect the person’s values
 Also requires signature of patient or legal
decision maker to make the form valid
The Heart of the Conversation
 Frame discussion based on patient-centered
goals for care (e.g. quantity vs. quality of life)
 Voluntary, can change or revoke at any time
 Comfort measures are always provided
 Discussion should include likely contingencies
for future medical treatment
 Ensure sound informed medical decision-making
 Conversation with Health Care Power of
Attorney (HCPOA) and “family” as defined by
patient
 Completion of POLST form
Example Discussion
Discussion should include likely contingencies
for future medical treatment…
Patient with advanced COPD
 Is BiPAP acceptable?
 Intubation/mechanical ventilation in ICU ok?
 Feeding tube placement?
 Long-term mechanical ventilation if patient
cannot be weaned?
 Would hospice or palliative care be preferred
to above?
How to complete the POLST
 Completed after discussion regarding
treatment preferences with person or
their health care agent/representative
 Any current advance directive should be
reviewed
 If any section is left
unchecked, the
highest level of care
must be provided
Part A: CPR
 Applies only when patient has no pulse
and is not breathing
 Does not apply to any other medical
circumstances
 Ex. respiratory distress, irregular pulse, etc.
 Would refer to sections B, C, and D
 Two choices
1. Attempt resuscitation
2. Allow Natural Death (Consider/discuss out of
hospital DNR)
 Comfort Measures will always be provided
Part B: Medical Interventions
 Applies to emergency medical
circumstances for a person who has a
pulse and is breathing
 Three choices:
1. Full Treatment: All life-sustaining treatments
are desired
 Includes intubation/advanced airway, mechanical
ventilation, cardioversion, critical care admit, etc.
 May or may not need to be transferred to the
hospital
Part B: Medical Interventions
2. Comfort Measures Only: desire those
interventions that enhance comfort
 Includes medications, positioning, wound care,
oxygen, etc.
3. Limited Additional Interventions: includes
comfort measures and medical treatment,
and cardiac monitoring as indicated
 Ex. Short term dehydration
 Intubation/mechanical ventilation is not used
 May transfer to hospital, but typically avoid critical
care
Part C: Antibiotics
 Stimulates consideration that antibiotics
are life-sustaining treatment
 Can help person clarify goals of care in
the context of advanced serious illness
 Three choices:
1. No antibiotics. Use other measures to
relieve symptoms
2. Determine use or limitation of antibiotics if
administration will improve comfort
3. Use antibiotics if life can be prolonged
Part D: Artificially Administered
Hydration/Nutrition
 For person who cannot take food or fluids
by mouth
 PA law presumes in favor of a patient
wanting artificial hydration and nutrition
unless individual expressed otherwise or
there is clear evidence of such
 Oral fluids and nutrition must always be
offered if medically feasible
Part D: Artificially Administered
Hydration/Nutrition
 Three choices:
1. No hydration and artificial nutrition by tube
2. Trial period of artificial hydration and
nutrition by tube
 Allows time to determine course of illness or
opportunity to clarify goals
3. Long-term artificial hydration and nutrition
by tube
Part E: Reason for Orders and
Signatures
 Whom orders were discussed with
 Include additional information supporting
the basis for the orders in the Patient
Goals/Medical Condition box
 Signature of provider
 Date the form
 Patient/representative signature
Reverse Side of the POLST
 Other contact section
 Includes
patient/representative
and provider names
and phone numbers if
clarification of orders
is necessary
 Directions for
Healthcare
Professionals
Roles and Expectations
The next slides provide an overview of
the roles of St. Luke’s care providers
using flow charts and a series of check
points to determine your understanding.
Review the processes and
responsibilities assigned to each role.
If a patient is seriously ill, terminally ill, or
with advanced frailty, POLST should be
discussed with the patient.
Patient presents to ED or
Direct Admit with Original
(PINK) POLST form
A Patient presents to
the ED or is a Direct
Admit and already
has a POLST form…
*If a UC i s not a vailable,
ta s ks are to be completed
by the RN
UC copies form
Is physician
who s igned
POLST on s ta ff
a t SLUHN?
YES
NO
Phys i cian is not on s taff - UC
veri fi es physician's PA Li censure
s ta tus a t
www.licensepa.state.pa.us
Does physician
ha ve a n
a cti ve/valid PA
l i cense?
YES
Phys i cian a cknowledges POLST i n HEC
(ED) or Phys i cian Progress Notes.
Incl udes: patient updates, any discussion,
cul tural issues, plans a nd counseling ,
Code/DNR/Resuscitation status
UC pri nts licensure
veri fi cation
NO
STOP!
POLST
ca nnot be
honored
Check Point #1
Q: A patient arrives at St. Luke’s with a
POLST form. The physician who signed
the POLST form is on staff. What happens
next?
A: The UC/RN makes a copy of the
POLST for the chart and the physician
acknowledges the presence of the POLST
in HEC or progress notes.
Check Point #2
Q: A patient arrives at St. Luke’s with a
POLST form. The physician who signed
the POLST form is NOT on staff. What
happens next?
A: The UC/RN verifies whether the
physician is licensed in Pennsylvania and
makes a copy of the license verification for
the chart. POLST may only be honored if
the physician is licensed in Pennsylvania.
UC Role
*If a UC i s not a vailable,
ta s ks are to be completed
by the RN
ED or Direct Admit
Unit Clerk Role
Is patient
admitted?
YES
NO
UC places the COPY of the
POLST and printed Physician
Licensure Verification under the
Advance Directives tab on the
chart.
UC places the ORIGINAL
POLST under the Discharge
Tab of the chart
UC notifies RN
of POLST
Did patient
expire in ED
prior to
admission?
YES
ORIGINAL POLST
form returned to
next of kin upon
request
NO
Patient discharged from
ED to
Home/SNF/Assisted
Living
UC ensures
ORIGINAL POLST
form goes with
patient
Check Point #3
Q: When a patient who has a POLST form
is admitted, what happens next?
A: The UC/RN places a copy of the
POLST form and physician PA license
verification under the Advance Directives
Tab on the chart. The Original pink POLST
form is placed under the Discharge tab of
the patient’s chart and the RN is notified of
the presence of the POLST.
RN Role
RN made aware of
POLST on admission
RN Role
RN makes note on SBAR
(presence of POLST form) AND
Notifies Case Manager during
care coordination rounds
Is patient
discharged to
Home/SNF/Assi
sted Living?
YES
RN ensures ORIGINAL POLST
goes with patient and
communicates to next
provider of care. A copy of
the POLST is maintained on
the chart
NO
NO
Did
patient
expire?
YES
ORIGINAL POLST
form returned to next
of kin upon request
**If a PINK POLST form is found in Medical Records, the
form should be returned to the patient's address of record
(generally, the Long Term Care Facility)
Check Point #4
Q: When notified that the patient has a
POLST form, what does the RN need to do?
A: The RN needs to:
 Place notation on the SBAR
 Notify the Case Manager during care
coordination rounds
Check Point #5
Q: Upon patient discharge, what happens
to the POLST form?
A: The RN ensures the patient’s original
POLST form goes with the patient on
discharge…it is the patient’s property! A
copy is maintained on the chart. The RN
also ensures communication to the next
provider of care as appropriate.
Physician Role
Physician Role
Does patient
ha ve existing
POLST?
YES
Does
pers on have advanced
chroni c progressive illness
a nd/or fra ilty, those who might die
i n the next year or a nyone of a dvanced
a ge with a s trong desire to
further define their preferences
of ca re i n their current
s ta te of
hea lth?
YES
NO
NO
STOP!
Phys i cian reviews POLST and
compl etes POLST discussion
wi th patient to ensure
conti nued a ccuracy a nd
upda tes wishes as
a ppropriate.
No further
a cti on
requi red.
Phys i cian completes POLST
di s cussion with patient
Does patient
wi s h to
compl ete
POLST?
YES
NO
Pa ti ent agrees to POLST
compl etion. Complete POLST
form wi th required signatures.
Document in progress notes.
Pa ti ent declined POLST a t this
time. Document in progress
notes.
Phys i cian s ubmits
a ppropriate
i nformation/codes for
phys ician billing.
Phys i cian gives POLST form to
RN or UC a nd i nforms RN of
POLST s tatus
CPT II codes: 1123F a nd 1124F
Eva l uation a nd Ma nagement Claims
codes: 99221, 999223, 9356, a nd 99357
Phys i cian also completes
DNR Order s heet
5.13.2014
Check Point #6
Q: Who can complete a POLST form in
Pennsylvania?
A: In Pennsylvania, a physician, physician
assistant (requires physician co-signature
within 10 days or less) or certified registered
nurse practitioner must sign the form
assuming full responsibility for the medical
indications of the orders and assuring that
they accurately reflect the person’s values.
Goals of FY 2015 Highmark Quality
Blue Hospital Pay for Value Program
Advanced Care Planning
 POLST implementation to communicate patient’s
end-of-life preferences across continuum of care
 For patients ≥ 18 years old discharged from a
hospital to a skilled nursing or long term care facility
 Target: POLST completion for at least 10% of this
patient population (measured through claims data)
 Providers may consider using prolonged visit timing
codes for Evaluation and Management Claims
 Anticipate expansion of this measure to outpatient
offices for FY 2016
 Other area hospitals are participating in this initiative
POLST Web Site Resources
http://www.aging.pitt.edu/professionals/resources-polst.htm
www.polst.org
Center for Ethics in Health Care
Oregon Health & Science University
www.wvendoflife.org
West Virginia Center for End-of-Life
Care POST
www.wsma.org/patients/polst
Washington State Medical
Association POLST
www.compassionandsupport.org/
Excellus Blue Cross Blue Shield
MOLST
www.aging.upmc.com/professiona University of Pittsburgh
ls/resources-polst.htm
Institute on Aging
www.dgim.pitt.edu/iepc/cqel.html
University of Pittsburgh
Institute to Enhance Palliative Care
http://cme.health.pitt.edu
University of Pittsburgh Internet
Based
Studies in Education and Research
On-line Training Module: Physician
Orders for Life-Sustaining Treatment
References
Author (2011). Advance Directives. #21 Administrative Policy and Procedure.
Bethlehem, PA. St. Luke’s University Health Network.
Black, J. S. (2010). Physician Orders for Life-Sustaining Treatment
Respecting Wishes Across Care Settings. Presentation on February 3,
2010 for St. Luke’s Hospital & Health Network.
Tuohey, J. F. and Hodges, M. O. (2011). End of Life: POLST reflects patient
wishes, clinical reality. Health Progress. (2011); March-April: 60-64.
POLST physician orders for life-sustaining treatment paradigm (2014), from
http://www.polst.org
Thank you!
 You have completed the POLST
educational program and are eligible to
receive…