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The New Indiana POST Program:
Improving the Care of Seriously Ill Patients
Robert Stone MD FAAHPM
Medical Director, Palliative Care
Indiana University Health Bloomington
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Objectives
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Objectives
1. Do we have to talk about dying? Yes.
2. Why? Because talking and planning help.
3. Because dying is different today.
4. Because HOPE is not a plan.
5. What are advance directives?
6. Why POST?
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“We all know we are going to
die, but we don’t believe it.”
• Morrie Schwartz,
Tuesdays with Morrie
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Jack and Dorothy Stone
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Average Human Life Expectancy
30,000 BC
15,000 BC
1,000 BC
2012
Life Expectancy 2010
•Average age at death - 79 years.
•If you live to 65, average age at death –
84
•If you live to 80, average age at death –
88
Typical Disease Trajectories to Death:
Terminal Illness
High
Function
Low
Murtagh F E M et al. Nephrol. Dial. Transplant. 2008;23:3746-3748
© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights
reserved. For Permissions, please e-mail: [email protected]
Typical Disease Trajectories to Death:
Progressive Chronic Disease
Murtagh F E M et al. Nephrol. Dial. Transplant.
2008;23:3746-3748
© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights
reserved. For Permissions, please e-mail: [email protected]
Typical Disease Trajectories to Death:
Frailty
High
Function
Low
Murtagh F E M et al. Nephrol. Dial. Transplant.
2008;23:3746-3748
© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights
reserved. For Permissions, please e-mail: [email protected]
Where do you want to die?
 More than 80% of people say that they want to
die at home, BUT….
 More than 80% die in an institution.
Hospital
Nursing Home
Home
60%
25%
15%
Woody Allen
“It's not that I'm
afraid to die,
I just don't want to
be there when it
happens.”
Traditional Approaches
•Advance Directives
–Appointment of Health Care
Representative or POA-HC
–Living Will
•Code status orders
–DNR vs Full Code
–Out of hospital DNR
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Where’s That Advance Care Directive?
Paula Span, New York Times 10/17/2013
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The POST Paradigm
 POST = Physician Orders for Scope of
Treatment
 Converts treatment preferences into medical
orders
 Who: Terminal Illness, Progressive Chronic
Disease, and Frailty
 Preferences to accept or decline treatments
 Transfers across treatment settings with
patient
 Recognizable, standardized form
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Section A: CPR Orders
• When does Section A apply?
– When patient has no pulse and is not breathing
Section B: Medical Interventions
• When does section B apply?
– When the patient still has a PULSE and is/is not breathing
Section B: Comfort Measures
• Requires active interventions to keep the
patient comfortable.
• Transfer to hospital only if comfort needs can
not be met in current location. For example:
• Uncontrolled symptoms (pain, shortness of
breath)
• Uncontrolled bleeding
• Laceration
• Fracture
• In general = No ICU
Does not mean do not treat!
Section C: Antibiotics
• Antibiotics for Comfort
– Examples: Urinary tract infection; wound
infection
– Literature suggests antibiotics are NOT needed
to ensure comfort in a patient with pneumonia
• Consistent with treatment goals—see Section B
– Stabilize condition
– Cure and prolong life if possible
Section D: Artificial Nutrition
• Discuss risks and benefits of feeding tubes
• For trial periods, discuss the goals of the trial
and when you will re-evaluate
Documentation of Discussion and
Patient Signature
• Patient/Representative Signature is required
Section F: Physician Signature
• Physician Signature required
• Cannot be signed by NP or PA
Who can/should have a POST?
– A terminal condition, like cancer
– An advanced chronic progressive illness,
like severe emphysema, heart, liver, or
kidney failure
– Advanced frailty, like dementia
– Patients who are seriously ill and whose
death within one year would NOT be a
surprise to their physician.
Who can prepare a POST form?
• Form can be prepared by a physician or
designee (e.g., nurse, social worker,
chaplain)
– Should not be filled out by attorneys,
patients, or family members without
physician or designee.
• Requires signature of patient or
representative.
• Requires physician signature to take effect.
What if the patient lacks decisionmaking capacity?
• May be completed by legal representative
– Health Care Representative (see back of
form)
– Health Care Power of Attorney
– Court appointed guardian
– But not any family member who has no
legal authority*
• Orders should be based on patient’s
expressed preferences, if known
How does the POST work in the
hospital setting?
• Form is valid in ALL settings
– Even if MD who signs it lacks admitting privileges
• Orders should be used to guide treatment plan
• POST can be revoked or modified if desired
How do we handle the form?
– Original POST is property of patient
– Keep with medications or in refrigerator
•Bright pink is recommended, but not
required
•Photocopies or faxes are valid
•Copies to all treating doctors
•File with local ambulance or fire
department
Where else can we turn for help?
• Respecting Choices www.RespectingChoices.org
• The Conversation Project
www.TheConversationProject.org
• IU Health Bloomington Advance
Directives Hotline: 812-353-9262
• Advance Directives Resource Center
www.in.gov/isdh/25880.htm
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Conclusion
• POST offers advantages over traditional
practices
• Indiana POST is available for use by qualified
patients
• POST provides clinicians across settings with
information about the patient’s plan of care
The first step is to have the conversation!
George Burns 1896-1996
“Statistics show, if
you live to be 100,
you've got it made.
Very few people die
past that age.”
The New Indiana POST Program:
Improving the Care of Seriously Ill Patients
Robert Stone MD FAAHPM
Medical Director, Palliative Care
Indiana University Health Bloomington
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