2. POST…. Physician Orders for Scope of Treatment 1 Respecting Patients’ Wishes at the End of Life EMS Train the Trainer EMS Train the Trainer

3. 2 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 O 2 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.

4. 3 After EMS was unable to intubate him at the scene, they inserted an oral airway, bagged, and transported the patient to the emergency department (2 nd hospital). Mr. Jan remained unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P of 105, RR of 8, and an O 2 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.

5. 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 4

6. What is POST? A physician order Can be completed by any provider but must be signed by qualified MD or DO Complements, but does not replace, advance directives Voluntary use Recognized by EMS as a valid DDNR 5

7. POST is for… Seriously ill patients* Terminally ill patients 6 * chronic, progressive disease/s

8. 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 7

9. 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.

10. Living Will* v. POST Living Will For every adult Requires decisions about myriad of future treatments Clear statement of preferences Needs to be retrieved Requires interpretation POST For the seriously ill Decisions among presented options Checking of preferred boxes Stays with the patient A physician’s order to be followed 9 *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42.

11. Why POST Works… MUST accompany patient Contains specifics Physician’s order—no interpretation is needed – POST orders are to be followed 10

12. Prompt for POST Completion 11 Would you be surprised if this patient died in the next year?

13. 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 (or copy) shall accompany the person to the receiving facility and shall remain in effect. POST Project Policy and Procedure 12

14. POLST is Spreading California, Georgia, Kansas, Missouri, New Mexico, Utah, Virginia, Washington, West Virginia, Wisconsin, New York, North Carolina, Maryland, Pennsylvania * * * * * * * * * * *

15. POST Pilot Project POST orders legally recognized in several states, including West Virginia. 8 regions in the state are conducting POST pilot projects over the next 2 years. Plan to make POST a uniform document recognized throughout Virginia.

16. EMS Participants List your participating EMS and transport groups here

17. EMS Participants List your participating EMS and transport groups here

18. POST Form

22. Section A: Resuscitation Only section applicable to EMS DNR orders only apply if a person is pulseless and apneic POST recognized as a valid Virginia DDNR – OEMS approval (Michael Berg) 21

23. 22 Section B Review care plan to be sure that palliative care measures available Institute palliative care measures as needed If meets admission criteria consider hospice

24. Section B: Level of Medical Interventions Limited Additional Measures – Includes comfort care described in previous section. However, may also use medical treatment, IV fluids, and cardiac monitoring as indicated. – Do not use intubation, advanced airway interventions, or mechanical ventilation. – Transfer to hospital, if indicated. Avoid intensive care. Full Treatment – Includes care described in 2 previous sections. – Use intubation, advanced airway interventions, mechanical ventilation, and cardiac defibrillation, as indicated. – Transfer to hospital, if indicated. Include intensive care, if indicated.

25. Section B: Level of Medical Interventions Comfort Measures – Treat with dignity and respect. Keep clean, warm, and dry. – Use medication by any route, positioning, wound care and other measures to relieve pain. – Do not transfer to the hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location.

26. Section C: Antibiotics Example of “Other Instructions”: Antibiotics may be used only as needed for comfort. (E.g., patients susceptible to UTI’s may reserve right to be treated with antibiotic for pain and discomfort.) 25

27. Section D: Artificial Nutrition/Hydration These orders pertain to a person who cannot take fluids and food by mouth. IV Fluids or Feeding Tube for Defined Trial Period: – Gives option of trying either of these to determine benefit to patient and/or for recovery from stroke or hydration from vomiting, etc. – Recommended trial for IV fluids = 2 to 7 days – Recommended trial for Feeding Tube = 30 days or less 26

28. Section E: Participants & Physician Signature 27

29. Section F: POST Reviews & Instructions Related EOL documents, if any, e.g., Living Will Signature of Patient or Legal Representative Signature of ACP Facilitator Directions for Health Care Professionals

30. POST Form Shall Always Accompany Patient/Resident When Transferred or Discharged!* * Note: Preferable to transfer with original current copy, but legible copies are to be honored as though they are the original. 29 On the top of the transfer packet!

31. “Where is the POST form?” 30

32. 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.

33. EMS Role in POST Pilot Project Know what the POST form looks like. Know location of POST form in transfer records. Honor DDNR During transfer, communicate to medical control that patient has a POST form and the contents of section A and B. At receiving facility, communicate that patient has a POST form and its location.

34. EMS Transport Service Roles Same as EMS, plus— Patient return to residence/facility, ask: – “Is there a POST Form?” – “Where is the POST form?” Make every effort to ensure the POST form is transferred with the patient back home or to the facility.

35. 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 “Where’s the POST form?” 34

36. Questions?