Transcript POST - Palliative Care Partnership of the Roanoke Valley

POST….
Physician Orders for Scope of Treatment
Respecting Patients’ Wishes
at the End of Life
Brandon Oaks
Staff Training
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An Index Case
Mr. Jan, a 71-year-old male with severe COPD and mild
dementia, was convalescing at a skilled-nursing facility after a
hospital stay for pneumonia. Mr. Jan developed increasing SOB and
decreasing LOC over 24 hours. The nursing facility staff called EMS
who found the patient unresponsive, with a RR of 8 and an O2 sat at
85% on room air. Although Mr. Jan had discussed his desire to forgo
aggressive, life-sustaining measures with his family and nursing
personnel, the nursing facility staff did not document his
preferences, inform the emergency team about them, or mention
his do-not-resuscitate order.
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After EMS was unable to intubate him at the scene, they inserted an
oral airway, bagged, and transported the patient to the emergency
department (2nd hospital). Mr. Jan remained unresponsive. He was
afebrile, with a systolic BP of 190 mm Hg, P of 105 , RR of 8, and an
O2 sat of 88% despite supplemental oxygen. He had diminished
breath sounds without wheezes, and a chest X-ray showed large
lung volumes without consolidation. Arterial blood gases showed
marked respiratory acidosis. The emergency department physician
wrote, “full code for now, status unclear.” The staff intubated and
sedated Mr. Jan and transferred him to the intensive care unit.
Lynn, et al. Ann Intern Med 2003;138:812-818.
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What went wrong?
(Could this happen in Roanoke?)
• Advance directives not documented
• DNR order not communicated in
transfer
• Fragmentation in care (2 hospitals)
• Overtreatment against patient’s wishes
• Unnecessary pain and suffering
• System-wide failure to respect pt’s
wishes
– Failure to plan ahead for contingencies
– No system for transfer of plan
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What is POST?
• A physician order
• Can be completed by a non-physician provider
but must be signed by qualified MD or DO
(Osteopath) or NP or PA allowed to sign under
their practice agreement.
• Complements, but does not replace, advance
directives
• Voluntary use
• Recognized by EMS as a valid DDNR
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POST is for…
Seriously ill patients*
Terminally ill patients
* chronic, progressive disease/s
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Purpose of POST
• To provide a mechanism to communicate
patients’ preferences for end-of-life
treatment across treatment settings
• To improve implementation of advance
care planning
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Expected Outcomes of Using POST
Process
• Improved continuity of care—Form
transferable across treatment settings
• Clearer communication of wishes
• Reduced hospitalization and inappropriate
life-sustaining treatments
– Fewer EMS transports
• More accurate representation of
preferences
• Higher adherence to wishes by medical
professionals.
Conversations that change over
time
Source: Carol Wilson, Riverside Health System; Used with permission
People with
Progressive
Illness: guided
planning
Healthy Adults:
Emergency
Planning
End Stage
Illness:
Physician
Orders for
Scope of
Treatment
Living Will* v. POST
Living Will
POST
• For every adult
• Requires decisions about
myriad of future treatments
• Clear statement of
preferences
• Needs to be retrieved
• Requires interpretation
• For the seriously ill
• Decisions among presented
options
• Checking of preferred boxes
• Stays with the patient
• A physician’s order to be
followed
*Fagerlin & Schneider. Enough: The Failure of the Living Will.
Hastings Center Report 2004;34:30-42.
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Why POST Works…
• MUST accompany patient
• Contains specifics
• Physician’s order—no interpretation
is needed
–POST orders are to be followed
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Prompt for POST Completion
Would you be surprised
if this patient died
in the next year?
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POST: Who Should Have One?
• Anyone choosing “Do Not Resuscitate”
• Anyone choosing to limit medical
interventions
• Anyone eligible/residing in a LTC facility
• Anyone who might die within the next year
Communication across Settings
The health care facility initiating the transfer
shall communicate the existence of the POST
form to the receiving facility prior to the
transfer. The POST form shall accompany the
person to the receiving facility and shall
remain in effect.
POST Project Policy and Procedure
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POST Can Be Completed In Many
Settings
Let’s Review
• True/False
– If a patient has a living will they don’t need a POST
form.
Let’s Review
• False. A living will is a more generalized
statement of wishes. A POST is physicians
orders for specific care wishes of the resident
and these orders must be followed
Let’s Review
• Which residents are candidates for completing
a POST form?
Let’s Review
• A POST form is appropriate for residents who
– Are terminally ill
– Are seriously ill with a progressive, chronic disease
– Are not expected to live more than a year
National POLST Paradigm Programs
Endorsed Programs
Developing Programs
No Program (Contacts)
*As of February 2013
POST Pilot Project
• POST orders legally recognized in
several states, including West
Virginia.
• Roanoke Valley is a POST Pilot
Project Region
• Plan to make POST a legal document
recognized throughout Virginia
Who is Participating in the Pilot?
•
•
•
•
•
•
•
Palliative Care Partnership of the Roanoke Valley
Friendship Health and Rehab Center
Richfield Recovery and Care Center
Brandon Oaks
Carilion Clinic: Roanoke Memorial Hospital
Lewis-Gale Medical Center (coming on board)
Hospice patients in the following hospices: Good
Samaritan Hospice; Carilion Clinic Hospice
EMS Participants
•
•
•
•
Roanoke County Fire & Rescue
Roanoke City Fire & EMS
Salem Fire & EMS
Local medical transport companies
– Carilion Clinic Patient Transport
– Life Care
– United
– Guardian
– Others
POST Form
The POST Form
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Section A: Resuscitation
A
 one only
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
☐ Attempt Resuscitation
☐ Do Not Attempt Resuscitation (DDNR/DNR/No CPR)
A DNR order in this section qualifies as a Durable DNR order. In no case shall any person other than the patient have
authority to revoke a Durable Do Not Resuscitate Order executed upon the request of and with the consent of the
patient himself. § 54.1-2987.1.B
• DNR orders only apply if a person has no pulse and is not
breathing
• Note: This section has 2 choices: Attempt Resuscitation and
Do Not Attempt Resuscitation: Check to see which box is
checked!
• POST Section A recognized as a valid Virginia Other DNR.
• When Do Not Attempt Resuscitation is checked, qualified healthcare
personnel are authorized to honor this order as if it were a Durable DNR
order
• OEMS approval (Michael Berg)
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Section B: Medical Interventions
B
 one only
Comfort
Measures
are always
provided,
regardless
of the level
of care
chosen
MEDICAL INTERVENTIONS: Patient has pulse and / or is breathing.
 Comfort Measures: Treat with dignity and respect. Keep warm and dry. Use medication by any route,
positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual
treatment of airway obstruction as needed for comfort. Transfer to hospital only if comfort needs cannot be met
in current location. Also see “Other Instructions” if indicated below.
 Limited Additional Interventions: Include comfort measures described above. Do not use intubation or
mechanical ventilation. May consider less invasive airway support (e.g., CPAP or BiPAP). Use additional medical
treatment, antibiotics, IV fluids and cardiac monitoring as indicated. (Hospital transfer if indicated. Avoid
intensive care unit.) Also see “Other Instructions” if indicated below.
 Full Interventions: In addition to Comfort Measures above, use intubation, mechanical ventilation, cardioversion
as indicated. Transfer to hospital if indicated. Include intensive care unit. Also see “Other Instructions” if
indicated below.
Other Instructions:
• If in the “terminal” phase, POST and advance directive should be
consistent
• Care plan should always be consistent with POST
• If Comfort Measures are selected consider hospice consultation
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Levels of Medical Interventions
• Comfort Measures
– Treat with dignity and respect.
– Keep warm and dry.
– Use medication by any route, positioning, wound care and
other measures to relieve pain and suffering.
– Use oxygen, suction and manual treatment of airway
obstruction as needed for comfort.
– Transfer to hospital only if comfort needs cannot be met in
current location. Also see “Other Instructions” if indicated
below.
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Levels of Medical Interventions
Limited Additional
Interventions
– Include comfort measures.
– Do not use intubation or
mechanical ventilation. May
consider less invasive airway
support (e.g., CPAP or BiPAP).
– Use additional medical
treatment, antibiotics, IV
fluids and cardiac monitoring
as indicated.
– Hospital transfer if indicated.
Avoid intensive care unit. Also
see “Other Instructions” if
indicated below.
Full Interventions
– In addition to Comfort
Measures above
– use intubation, mechanical
ventilation, cardioversion as
indicated.
– Transfer to hospital if
indicated. Include intensive
care unit.
– Also see “Other Instructions”
if indicated below.
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Section C: Artificial Nutrition
• These orders pertain to a person who cannot take
food by mouth
• Feeding tube for a defined trial period:
• Gives option to determine benefit to patient and/or recovery
from stroke, etc.
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POST Sections (Other)
Discussed with
Physician Signature and contact info
Patient/Authorized Decision Maker
Authority to sign patient if patient is
incapacitated
Facility of POST form origin
Name and signature of Facilitator
Instructions
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Original Form Shall Always Accompany
Patient/Resident When Transferred or
Discharged!
On the top of the transfer packet!
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“Where is the POST form?”
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At Transfer
• The yellow POST form placed in a red
envelope with a label and placed at top of
transfer documents:
– “POST Order Form---This Form is to Accompany
the Resident Upon Transfer or Discharge; if
resident returns to (name of facility), please
return this form to: (address of facility)
• EMS, hand this envelope to person in charge
of receiving resident/patient transfer
documents.
Let’s Review
• What color is the POST Form?
• True/False: In order for a POST form to be
valid, it must be signed by an MD or DO
licensed in Virginia
• True/False: EMS will not recognize the POST
form as a valid DDNR
Let’s Review
• Section A of a resident’s POST form says he
wishes to not be recussitated. Section B of a
resident’s POST form indicates that the
resident wants Comfort Measures. You find
the resident unresponsive, has shallow
respirations with long periods of apnea, and a
pulse of 100. What should you do?
Let’s review
• As long as the resident’s comfort can be
provided for at the facility, this resident is not
to be transferred to the hospital.
• How would you handle it, if a family member
were insisting that you send the resident to
the hospital?
How to Complete a POST Form
• Must be completed by a physician or by a
non-physician health care professional who
has been trained as a POST Advance Care
Planning Facilitator (ACPF).
• Must be based on patient/resident
preferences
• Must be signed by an MD or DO; may be
signed by an NP or PA if within their practice
agreement.
Why an Advance Care Planning
Facilitator (ACPF)?
Why an ACPF?
• Has received training in having discussions
with patients and POA’s about preferences for
EOL care
• Training was based on our POST form
• The Advance Care Planning process takes
about 45 minutes and often involves follow-up
and/or additional sessions
• It is important that POST form is not just a
check off sheet---an ACPF can make sure
people know and understand their options
Who are the Trained ACPF’s at
Brandon Oaks?
•
•
•
•
•
Dr. Soheir Boshra, MD
Melissa Conner
Kim Bain
Jean Craddock
Nancy Patterson
Steps to Starting POST Process
For the Resident
• Identify residents who might be appropriate
for POST process (due to condition,
resident/POA request, or else resident is
admitted with a POST form).
• Notify a POST ACPF that resident was
admitted with a POST form or resident might
need a POST form completed
Steps to POST Process
• Resident’s physician or ACPF completes POST
Form (or reviews POST form that came with
resident upon admission).
– If ACPF completes, then physician notified that
there is a POST form to sign.
Steps to POST Process
• Person completing POST Form:
– Document in Interdisciplinary Notes and Plan of
Care
– Enter the orders into the active medical record
consistent with those in the POST order set.
– Make copy of POST form to give to the social
worker and to the resident or their substitute
decision maker.
– Original of POST form goes in a clear plastic sleeve
behind Advance Directives tag
Steps to POST Process
• Person completing POST form (continued):
– Place yellow POST sticker on the front of chart:
POST
– Notify nursing unit charge nurse and social worker
that POST has been signed and what those POST
orders are
– Review POST form with resident/POA periodically
(at quarterly team meetings) and prn (i.e. when
condition changes)
Transfer/Discharge
• Prior to discharge/transfer to another care
setting, the resident’s nurse or social worker
arranging the transfer will notify receiving
facility by telephone call of POST form.
• Put original POST form into a labeled red
envelope and place at top of transfer
documents.
• Unit Manger or Charge Nurse: Make sure a
photocopy of the current POST form is in
Advance Directives section of the resident’s
chart
Envelope Label
ORIGINAL
POST/DDNR
Forms Enclosed
Forms are to accompany Resident upon
Discharge/Transfer
PLEASE RETURN ORIGINAL
FORM IN THIS ENVELOPE
TO:
The Red Envelope for
Transfer/Discharge
Let’s Review
• Where does the current original copy of the
POST form go in the chart?
• Who may help a resident/POA complete a
POST form?
• What do you do if a resident with a POST form
is to be transferred to another health care
setting or home with hospice care?
Let’s Review
• Upon transfer:
– Call the receiving facility and notify of POST
– Make sure a photocopy of POST form is in the
Advance Directives section of the chart
– Put original copy of POST form in labeled red
envelope and put on top of transfer packet
– Alert EMS/transporter of the POST form
Communicate, Communicate,
Communicate!
• Make sure receiving care setting knows there’s
a POST form.
• Make sure the EMS or transport personnel
know that there is a POST form and show
them where it is.
• Ask EMS/transporter to point out POST form
to person receiving the resident.
• When resident returns, ask “Where’s the POST
Form?”!!!!!!
Resident Dies at Brandon Oaks
• If the resident dies at Brandon Oaks, the
original POST form is to be placed in the
Advance Directives section of the closed
medical record by Medical Records.
Resident is Admitted with a POST
• Admissions: Notify receiving unit of POST
• Unit Support: Place the original in a clear
plastic sleeve in the Advance Care Planning
section of the chart. Notify PCP and POST
Advance Care Planning Facilitator.
• PCP or ACPF:
– Review the POST form with the resident;
– Enter orders consistent with those in the POST
form.
Revoking/Making Changes to POST
• If the resident wishes to change the POST form, the
original POST form shall be voided, and a new one
completed.
Revoking/Changing a POST Form
• To change POST, the current POST form must be
voided and a new POST form completed. If no
new form is completed, full treatment and
resuscitation may be provided.
• As long as the patient can make his/her own
decisions, then the patient can revoke consent for
POST and also may request changes to POST.
Revoking/Making Changes to POST
• If a patient tells a healthcare professional that he
wishes to revoke his consent to POST or change
POST , the healthcare professional caring for the
patient should draw a line through the front of the
form and write “VOID” in large letters on the
original, with the date and their signature, and
notify the patient’s physician. A new POST form
then may be completed if desired by the patient.
• The physician or a POST ACPF may complete the
new form.
Revoking/Changing POST
• If “Do Not Attempt Resuscitation” is checked in
Section A and the patient has signed this form, no
one has the authority to revoke consent for the
DDNR order other than the patient as stated in
the Code of Virginia section 54.1-2987.1.
Revoking/Changing POST
• If the patient signs this form, then the patient’s
overall treatment goals should be honored if the
patient later becomes unable to make decisions.
•If the patient is unable to make healthcare
decisions, a legally authorized medical decision
maker, in consultation with the treating physician,
may sign this form, revoke consent to, or request
changes to the POST orders (except in section A as
noted above) to continue carrying out the
patient’s own preferences in light of changes in
the patient’s condition.
Revoking/Changing POST
– The voided POST form shall be placed in the
Advance Directives section of the thinned chart.
Who Does What?
• Let’s review.
Questions?
Everyone!
(Whether Medical, Nursing, Social Services,
Admissions or MDS)
Keep your eyes
and ears open to
residents who
might need ACP
and a POST form
Take-Home Messages
• POST provides a better means than AD to
identify and respect patients’ wishes
• POST completion will improve end-of-life care
throughout the system
• Use of POST will require communication to
make it work in your community
• Know your role.
• “Where’s the POST form?”
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