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1 Presented for Healthcare Providers by: POLSTPhysician Orders for Life-Sustaining TreatmentIntro to Illinois’ s new idph uniformDNR Advance DirectivePresented for Healthcare Providersby:Revised 8/01/2013
3 Objectives By the end of this session, participants will be able to: Understand the POLST Paradigm and how patient wishes are determined and documented in a standard formDescribe the relationship between a Power of Attorney for Healthcare and a POLST form, and when each is appropriate for patient completionRecognize the importance of healthcare staff being properly educated regarding interpreting POLST forms during emergencies and other relevant circumstances
4 IDPH DNR Advance Directive… now meets national POLST standards Illinois recently modified the current IDPH DNR Advance Directive to meet the national POLST standards used in other statesPOLST stands for “Physician Orders for Life-Sustaining Treatment”POLST reduces medical errors by improving guidance during life-threatening emergencies3
5 POLST Use in the United States The POLST Paradigm is now in the majority of statesOregon released the first POLST form in 1995Gradually expanded throughout the U.S.15 states with endorsed programs28 states developing programs (including IL)The national POLST Paradigm Initiative Task Force aids state programs with patient safety, quality improvement, and educational resources6
6 4th version of IDPH DNR form In 2000, Illinois used the “orange form” out of hospital DNR form. This was only for emergency transport and the DNR order had to be rewritten at each new facility.In 2005, the IDPH Uniform DNR Order form was created that applied to all facilities and a patient only needed one form.In 2006, Some facilities were confused if the form had to be used for every in-hospital DNR order (it did not), so it was renamed the IDPH Uniform DNR Advance Directive.Now, it is still called the IDPH DNR Advance Directive, but many people may use the shorthand of ‘DNR form’ or POLST since it uses the national POLST “paradigm” as a way of talking to patients and documenting their wishes for life-threatening emergencies.
7 Benefits of IDPH DNR/POLST in Illinois Promoting Patient-Centered CarePromotes quality care through informed end-of-life conversations and shared decision-makingConcrete Medical Orders that must be followed by healthcare providersEasily recognized standardized form for the entire state of IllinoisFollows patient from care setting to care setting5
8 Key Factors Work Together to Help POLST Work ColorLocationTransportabilityOrganizationsshould assistpersons inchoosing astandardlocation in theirlocal area where POLST is keptDesigned tostay with thepatient as thepatient istransported toa new facility& must behonored in all locationsThe pink colorhelps the formstand out foreasieridentification10
9 Who is IDPH DNR/POLST Designed For? Focusing on patients as partners in their care.The POLST paradigm is designed for:Patients facing life-threatening complications, regardless of age; and/orPatients with advanced frailty and limited life expectancy; and/orPatients who may lose the capacity to make their own health care decisions in the next year (such as persons with dementia); and/orPersons with strong preferences about current or anticipated end- of-life care.Slide 9: POLST is not for use by the general public. It is specifically meant to be used by patients who meet these criteria.
10 Screening Question A POLST discussion is appropriate if: One Year is a Rule of Thumb…A POLST discussion is appropriate if:You would not be surprised if this person died from their illness(es) within the next yearThe patient suffers from a severe illness and has a preference about the intensity of his/her care
11 Advance Care Planning Over Time Maintain and Maximize Health, Choices, and IndependenceFirst Steps:Complete a PoA. Think about wishes if faced with severe trauma and/or neurological injury.Next Steps:Consider if, or how, goals of care would change if interventions resulted in bad outcomes or severe complications.Last Steps:End-of-Life planning - establish a specific plan of care using POLST to guide emergency medical orders based on goals.Healthy and IndependentAdvancing Chronic Illnesses and Functional DeclineMultiple Co-Morbidities and Increasing FrailtyThe segmented bar in the middle represents the 3 “phases” of the Advance Care Planning “Life Cycle.” There is much information here, and most likely it will need to be briefly summarized in order to get through the entire presentation.The First Phase begins at adulthood. Once someone becomes an adult, they should be encouraged to start advance care planning as a healthy life habit. For a Healthy and independent adult, there are only a few advance care planning “tasks”. The first is to consider “Who in my life would I trust to represent my medical wishes if I couldn’t speak for myself?”. The second is to put that choice in writing in the form of a power of attorney for healthcare document. The third is to consider “If I suddenly became irreversibly neurologically devastated, ie., vegetative, would I want ongoing treatment or would I want to be allowed to die?” (be aware that this is a controversial subject for observant Catholics). The fourth is to notify the selected agent, and give that person a copy of the document. These are the “First Steps”.The Next Phase begins when a patient has a chronic illness that has begun to advance such that there is a functional decline. For this patient, the life habit continues, and is built upon the considerations in the First Phase. Now it is time to think about one’s specific conditions and the specific kinds of deterioration that can be can be expected with those conditions. For example, a person who has COPD is now requiring oxygen use at home, and/or is experiencing hospital admissions for acute exacerbations. That patient should understand the risk of being intubated and the nature of that procedure including its benefits and burdens. The patient should also consider whether, if unweanable, tracheostomy and longer-term care in a facility that treats patients on ventilators would be acceptable, and if so, would there come a point when it would no longer be acceptable? If there are no limitations of treatment desired at this point, there is not a new document to complete here, but specific discussion about specific treatment wishes is appropriate, with both the primary care provider as well as the identified agent. These are the “Next Steps”.The Last Phase is when a patient is likely to be in the last year or so of life, as mentioned. This is the patient with multiple comorbities and/or increasing frailty. In this phase, it is possible that the person making decisions is not even the patient, but instead the substitute decision-maker (who is ideally also the assigned agent with Power of Attorney for Health Care). In this phase, there are specific decisions to be made, including wishes about CPR in case of cardiac arrest, and in other critical conditions, level-of-treatment wishes based on patient goals, which can range from strictly comfort care all the way to aggressive treatment with all medically indicated means. These are the “Last Steps”, and are documented on the POLST form so that ALL providers who may encounter this patient in an emergency situation will have guidance regarding the desired treatment(s).Document on Power of Attorney formDocument on IDPH DNR form
13 The IDPH DNR/POLST Document 3 Primary Medical Order SectionsCPR for Full ArrestYes, Attempt CPRNo, Do Not Attempt CPR (DNR)Orders for Pre-Arrest EmergencyFull TreatmentLimited TreatmentComfort OnlyArtificial NutritionNoneTrial periodAcceptableSlide 13: This slide shows the general outline of decision categories in the POLST form, as compared to the “old” IDPH DNR Advance Directive to which we are accustomed. We will go in detail through each of the sections. One of the most important things to notice immediately, is that, unlike the old form, the mere existence of a POLST form does not imply that the patient is DNR in case of a cardiac arrest. This is a critical change to this Section of the form, and an important safety issue. Section B still addresses pre-arrest emergencies, but the levels of treatment instructions are much more detailed and understandable compared to the old form. And Section C is brand-new.Fields in blue are NEW
14 Section “A”: Cardio-Pulmonary Resuscitation Code Status – only when pulse AND breathing have stoppedSlide 15: Again, notice that unlike the previous versions of the form, the POLST form may also be used when a patient wants to document that s/he in fact WOULD accept CPR in case of cardiac arrest. Of course, “Yes to CPR in case of cardiac arrest” is our default instruction in any case. And with the old form, there was no reason to even have it if the patient wanted CPR in case of cardiac arrest. But because the POLST form now allows for a yes or no answer, the form has become somewhat more complex. The good news is, the same content that adds complexity also supports patients in documenting their wishes more specifically and allows them to know that their wishes will be followed.There are multiple kinds of emergencies. This section only addresses a full arrest event (no breathing or pulse), and answers “Do we do CPR or not?”NEW! Patients can use this form to say YES to CPR, as well as to refuse CPR.
15 Section “B”: Medical Interventions Do Not Resuscitate does NOT mean Do NothingThree categories explaining the intensity of treatment when the patient has requested DNR for full arrest, but is still breathing or has a pulse.Comfort – patient prefers symptom management and no transfer if possibleLimited – no aggressive treatments such as mechanical ventilationFull – all indicated treatments are acceptableSlide 17: Section B now is now formatted according to intensity of treatment wishes in pre-arrest situations. Which level is selected will be based on the patient’s specific medical conditions, plus what is medically feasible, plus the patient’s own goals of care. There are three levels of treatment, which can be thought of as “Strictly Comfort Care”, “Limited but Noninvasive Medical Interventions”, and “Full Treatment with all Medically Indicated Treatments” (a.k.a. the “Intubation and Mechanical Ventilation” intensity level).
16 Stoplight Metaphor for Medical Interventions Stop – Caution – GoStop (Patient Refusal)Caution (Limited Treatment)Go (Full Treatment)The instructions for “Stop” and “Go” are clear – it is with caution (limited treatment) that providers need to slow down and look around to determine what actions are appropriate.
17 Section “B”: Medical Interventions Use “Additional Orders” for other treatments that might come into question (such as dialysis, surgery, chemotherapy, blood products, etc.).An indication that a patient is willing to accept full treatment should not be interpreted as forcing health care providers to offer or provide treatment that will not provide a reasonable clinical benefit to the patient (would be “futile”).Slide 19: Note here that a treatment is said to be “futile” if it does not meet the goals for patient. (The challenge here is that it is not always clear whose goals are being considered: is it the patient’s goals or the providers’ goals being considered?). A full discussion of the meaning of “futility” is beyond the scope of this presentation, but the key concept is that although a patient may be willing to receive a treatment, that willingness does not force a provider to go against medical standards of care to provide it.
18 Section “B”: Medical Interventions “Check One” plus any Additional Orders Note: The “Check One” instruction in Section B only refers only to the three primary choices.You may also put instructions next to Additional Orders.There is currently communication with IDPH asking them to remove the box next to Additional Orders to avoid this confusion.
19 Section “B”: Medical Interventions Yes to CPR in Section A requires full treatment in Section BIf choosing “Attempt CPR” in Section A, Intubation and Mechanical Ventilation is required in Section B.Why? If limited measures fail and the patient progresses to full arrest, the patient will be intubated anyway, thus defeating the purpose of marking Comfort or Limited.
20 Section “A” choices influence medical interventions in Section “B” Yes! Do CPRFull TreatmentComfort Measures*orDNR: No CPRNote that DNR for full arrest does NOT require documentation of a qualifying condition when requested by a Surrogate. This is because once the patient goes into full arrest, they now have a qualifying condition. It would not make sense to wait until that moment to make appropriate plans.Limited Interventions*orFull Treatment*Requires documentation of a “qualifying condition” ONLY when requested by a Surrogate.17
21 For Example…85 year-old gentleman admitted from home through ED with severe pneumoniaThe patient is increasingly hypoxic and may be confusedPatient refuses the vent x3.There is a DNR order on the chart.The physician feels DNR does not apply to potentially reversible conditions and begins full resuscitation.
22 POLST Clarifies Unclear Guidance 85 year-old gentleman admitted from home through ED with severe pneumoniaThe patient is increasingly hypoxic and may be confusedPatient refuses the vent x3.There is a DNR order on the chart.Comfort only is marked for medical treatment. Intensive symptom management is started and resuscitation is not initiated.
23 For example…A 59 year-old woman being treated for breast cancer arrives at the ED with sepsis.In the ICU, she is on oxygen and maxed-out on pressors.She has a DNR order on the chart.Staff are concerned they are violating the patient’s wishes.
24 POLST Addresses Ethical Concerns A 59 year-old woman being treated for breast cancer arrives at the ED with sepsis.In the ICU, she is on oxygen and maxed-out on pressors.She has a DNR order on the chart.Limited treatment is marked for medical treatment. Staff can feel comfortable they are honoring the patient’s wishes.
25 For example…67 year-old gentleman presents to ED with chest pain and SOB.He is in pain and confused.The cardiologist wants to take him for a cardiac cath and possible stent.The patient’s nurse calls the physician to inform her that the patient has a prior IDPH DNR order on the chart.There is confusion whether the patient would want to be sent for the procedure anyway.
26 POLST Provides Guidance for Treatment 67 year-old gentleman presents to ED with chest pain and SOB.He is in pain and confused.The cardiologist wants to take him for a cardiac cath and possible stent.The patient’s nurse calls the physician to inform her that the patient has a prior IDPH DNR order on the chart.Full treatment is marked for medical treatment and he is immediately sent for the recommended treatment.This slide highlights the difficulty providers have when responding to an emergency when the complete medical history is not immediately available the only information they have is a DNR form that doesn’t apply until the patient goes into full arrest. The staff would have to go back and comb through the past medical records to find the conversation with the patient and the patient’s goals given his medical condition. The POLST form allows providers to act quickly when minutes count which gives them the time they need to get to this important information in the past medical history.
27 Don’t Forget DNR for Procedures… Best Practice: DNR Is Not Automatically LiftedConsent needs to be obtained to change an existing DNR order to full code, even during a procedureDiscuss appropriateness of DNR in light of procedure and objectivesIf suspended, specify length of timeInform procedurists of code statusPhysicians may still say to the patient that they need the ability to reverse iatrogenic complications caused by the surgery itself or anesthesia, and thus need to suspend the DNR for the period of the surgery and possibly for an agreed upon time afterward. The key point here is that the patient is both informed and agrees to the suspension.
28 Creating More Accurate Orders Some institutions have created orders to better capture the distinction of these categories, such as DNR-Comfort, DNR-DNI, or DNR-Full Treatment.Hospitals are NOT required to complete this form when writing in-hospital DNR orders for the first time.Complete a IDPH DNR/POLST form if the patient/legal representative wishes to continue DNR code status or limit emergency medical interventions after discharge.DNR refers to the orders in Section A, whereas Comfort or DNI or Full refers to the orders in Section B.
29 Oregon Study ResultsOver 25,000 people enrolled in Oregon’s registry28% wished to receive CPR if needed.72% had a “DNR” order.50% of patients who had a DNR order wanted to be hospitalized and/or receive other treatments.JAMA. 2012;307(1):34-35
30 Section “C”: Artificially Administered Nutrition Nutrition by tube can include temporary NG tubes, TPN, or permanent placement feeding tubes such as PEG or J-tubes.A trial period may be appropriate before permanent placement, especially when the benefits of tube feeding are unknown, or when the patient is undergoing other types of treatment where nutritional support may be helpful.
31 Of 25,000 People in Oregon CPR group DNR group 2% 18% 22% 24% 60% 74% The majority of the CPR group wanted a time-limited trial of tube feeding to see if the feeding could restore an acceptable level of functioning. The majority of people in the DNR group did not want tube feeding.Persons wishing to accept long-term tube feeding was low for both groups.CPR group22% Long-term60% Trial18% NoneDNR group2% Long-term24% Trial74% NoneSlide 35: Again, this slide reinforces the concept that “DNR does not mean Do Nothing”. It also demonstrates that there is a broad diversity of choices regarding artificial nutrition.Long-Term feeding tubeTime-limited TrialNo feeding tubeJAMA. 2012;307(1):34-3531
32 Section “D”: Documentation of Discussion The form can be signed by:The patientThe agent with a PoA (when the patient does not have decisional capacity)The designated Healthcare Surrogatewhen the patient does not have decisional capacity and has no PoA or applicable Advance Directivea parent of a minor child is a surrogateA guardian is also a surrogateSlide 37: The legal representative may only sign this document if the physician has determined that the patient is unable to give his/her own informed consent on these matters.
33 Quick Refresher on Decision-Maker Priority Start at the top and move down the listPatientDo not move on until patient has been evaluated by the attending physician who documents the patient lacks decisional capacity and is not expected to regain capacity in time to make this decisionPower of Attorney for HealthcarePatient has completed and signed this Advance DirectiveSurrogate (when you can’t speak to patient and no PoA)Guardian of the personSpouse/ Civil partnerAdult childrenParentsAdult siblingsGrandparents/childrenClose Friend
34 Decisional CapacityIt’s not all or nothing.Before turning to a PoA or Surrogate, assess and document Decisional Capacity.The patient may be able to make some decisions even if s/he can’t make all decisions.Patients who are minors should be offered the opportunity to participate in decision-making up to their level of understandingStudies consistently show that decisions made by others are more aggressive and not as accurate as what the patient would choose for him/herself.Slide 38: Remember that the patient has the right to accept or decline medical treatment as long as s/he has the capacity to do so. Patients may have decisional capacity for one task but not another, depending on the complexity and gravity of the decision-making task in question. For a substitute decision-maker to be authorized to act on behalf of a nondecisional patient, the physician must determine based on medical judgment that the patient lacks decision making capacity. Details of such a determination are beyond the scope of this talk. Of course, it is ideal to have a discussion about care preferences near the end-of-life with the patient him- or herself whenever possible, especially given that the literature consistently shows that substitute decision-makers do not make the same decisions that patients would have, and their choices tend toward more aggressive care than the patients would have wanted.
35 Section “D”: Documentation of Discussion According to IDPH, “one individual, 18 years of age or older, must witness the signature of the patient or his/her legal representative’s consent... A witness may include a family member, friend or health care worker.”When the form is completed by a person other than the patient, it should be reviewed with the patient if the patient regains decisional capacity to ensure that the patient agrees to the provisions.Direct care providers are persons who have control over the patient’s medical choices and treatment plan.Common sense and practicality must be used here: the purpose of a witness signature is to provide a “third party” protection of the patient, to assure that the patient is in fact engaging in a fully informed decision-making process and is not being coerced by the physician. If a resident physician or another nurse signs as a witness, does this comfortably demonstrate to all that the patient is not being coerced by the attending physician? There is a risk that the answer could be no. On the other hand, there are circumstances, for example, in home hospice, where there are very few persons available to sign as a witness. Follow your own institutional guidance/policies.
36 Section “D”: Documentation of Discussion Adults with an IDPH DNR/POLST are also encouraged to complete a Power of Attorney (PoA).Extreme care should be exercised if the PoA or Surrogate wishes to reverse the direction of care previously established by the patientFor example, the patient requested Comfort or Limited Treatment, but the PoA or Surrogate wants Full TreatmentChanges to a form should be based on evidence of the patient’s wishesA power of attorney can answer the wide range of questions that are not covered by this form, and can provide consents within the parameters already established by the patient.If the patient has chosen DNR, s/he has planned for the eventuality of a full arrest situation, has discussed this with their physician, and has legally documented their refused of the procedure. The PoA can make new decisions, and must make those decisions in a manner in which the patient would make them for himself or herself. Thus, with evidence of the patient’s refusal, it would take a rather extraordinary set of circumstances where providers could override an informed refusal of a procedure by the patient.With Limited or Comfort interventions, the patient has refused some elements of treatment and again, that refusal should be honored by both providers and a PoA. However, a medical evaluation may provide new evidence, and the PoA can make decisions about those elements of care that the patient has not previously refused.
37 Section “E”: Signature of Attending Physician The attending physician must sign and date the form for the medical orders to be valid.“"Attending physician" means the physician selected by or assigned to the patient who has primary responsibility for treatment and care of the patient and who is a licensed physician in Illinois. If more than one physician shares that responsibility, any of those physicians may act as the attending physician.” 755 ILCS 40/10
38 Requirements for a Valid Form Use White or Ultra Pink paperPatient nameResuscitation orders (Section “A”)3 SignaturesPatient or legal representativeWitnessPhysicianAll other information is optionalPink paper is recommended to enhance visibility, but color does not affect validity of formPhotocopies and faxes ARE acceptable.
39 Who Can Assist in Preparing the Form? Best practice suggests use of those trained in the POLST Conversation such as (among others):PhysiciansSocial WorkersNursesChaplainsCare ManagersEthicistsPhysician Assistants and Nurse PractitionersFind an example of a POLST conversation at:
40 POLST is a Process, Not a Form The form is a documentation tool.POLST should not be used as a check-box form, or as a replacement for an informed conversation between patients, families and providers to:Identify goals of treatment.Make informed choices.The conversation should be documented in the medical record, along with a copy of the completed IDPH DNR/POLST form.
41 Reverse Side: Guidelines and Instructions Completion of the form is always voluntary.
42 Potential System Concerns Signing physician doesn’t have privileges hereOrders still must be translated into specific institutional ordersSuggest using “Pt is DNR per IDPH DNR order” and have that order signed by assigned staff attendingOur physician has never seen this patient beforeLaw indicates DNR must be honored in all care settingsProtected from liability for following an IDPH DNR form in good faithDeveloping best practices for storing, locating, and transmitting document between care settingsInstitutions should standardize where the document is located so that it is easily available during an emergency, but also protects the patient’s privacy
43 Can I Use POLST Just as a DNR form? Yes - Section A (requesting CPR or DNR) is the only required sectionCross out other sections and mark “No decisions made”If left blank, boxes could be filled in later, effectively creating a physician order that the physician is unaware of or may not agree withMakes it clear that patient did not address the subjects in the other sections – decisions can be made at a later date by creating a new form
44 What Should I Do with an Older IDPH DNR Form? Continue to follow older IDPH DNR Advance Directives.Update the older form to the new form when it is feasible.Review the form with the patient or legal representative when a change in the patient’s medical condition, goals, or wishes occurs
45 This presentation for the POLST Illinois Taskforce has been made possible by in-kind and other resources provided by:
46 Training EventsIf you are attending a formal POLST training event, PLEASE help us with our quality improvement efforts and grant obligations by:Signing in for attendanceComplete your survey and turn it inLook for and complete a follow-up in about 6 weeks
47 THANK YOU! Original presentation developed by Kelly Armstrong, PhD for the Illinois POLST Taskforce.Contact:
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