Practitioner Orders for Life Sustaining Treatment Effective July 1, 2013

What is POLST? Practitioner Orders for Life Sustaining Treatments Was signed into law December 2011 and facilities must be in compliance with POLST by July 1, 2013. Single page order form Addresses life-sustaining treatments Scope of care Option to return to hospital Artificial nutrition Code status Will replace the New Jersey “Out of Hospital DNR Form”

Where did POLST come from??? POLST began in Oregon in 1991. Developed initially for nursing home residents who were often transferred back and forth between the hospital, nursing home or their home. Expanded to more than half of US. Studies have shown that POLST is effective in providing care that is consistent with patient wishes. Tolle SW, Tilden VT, Nelson CA, Dunn PM: A prospective study of the efficacy of the PO(L)ST: Physician Order Form for Life-Sustaining Treatment. J.Am Geriatr Soc 1998;46:1097-1102.

Who is the POLST for? Recommended for people entering their final years of life, regardless of age For those diagnosed with advanced illness or frailty A practitioner would not be surprised if this person died within the year For those who want to better define and make clear their preferences of care

Who completes the POLST? In the State of New Jersey, The Patient or Surrogate and Physician or Advanced practice nurse NOT Lawyer Social Worker Nurse Other members of the team

Who signs the orders and consent? In the State of New Jersey: Signs the orders: Physician Advance Practice Nurse Signs the consent: Patient Surrogate Decision Maker

Core elements of POLST Actionable medical orders Complements Advance Directives Brightly colored format > green Portable across all health care settings It’s the law! Hospital Nursing facility Office Home care Hospice care

Differences between POLST and Advance Directive (AD) Who completes the form Physician or Advance Practice nurse Patient, often with a lawyer Time frame Current care Future care Who The seriously ill All adults Portability Person and Provider responsibility Patient and family responsibility Periodic review of form Provider responsibility Health care agent/ surrogate role Able to engage in discussion to compose form with physician if patient lacks capacity. Cannot complete Emergency Situation Medical order that must be honored, starting with EMT’s Cannot be interpreted or followed by healthcare professionals in an emergency situation. POLST FORM COMPLEMENTS AN ADVANCE DIRECTIVE AND IS NOT INTENDED TO REPLACE IT. - Still should fill out advance directives when healthy and have discussion with family, especially anyone you named as your durable power of attoryney for healthcare , or health care representative. Advance directives cannot be interpreted or followed by health care professionals in an emergency ORDERS NEEDS.

Core elements of POLST Must ask of existence and honor the most recent POLST Copy the original POLST and place on chart Original POLST form return to patient on discharge To void a POLST, draw a line through all sections, write “VOID” in large letters, and sign and date Meridian Health will be building POLST into computerized documentation systems

Steps for a Physician or Advance Practice Nurse to Complete POLST Having the ‘end-of-life’ discussion: Check for understanding of condition Share information about prognosis Establish goals of care Complete form and recommend treatment

FRONT

BACK

Section A - Goals of Care What are the specific goals that we are trying to achieve by this treatment plan of care? This can be determined by asking the simple question: “What are your hopes for the future?” Examples include but not restricted to: Longevity, cure, remission Better quality of life Live long enough to attend a family event (wedding, birthday, graduation) Live without pain, nausea, shortness of breath Eating, driving, gardening, enjoying grandchildren Medical providers are encouraged to share information regarding prognosis in order for the person to set realistic goals.

Section B – Medical Interventions [] Full treatment [] Limited treatment When "limited treatment” is selected, also indicate if the person [] prefers or [] does not prefer to be transferred to a hospital for additional care. [] Symptom treatment only – examples: IV medication to enhance comfort may be appropriate for a person who has chosen “symptom treatment only.” Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), or bi-level positive airway pressure (BiPAP). Comfort measures will always be provided.

Section C – Artificially Administered Fluids and Nutrition Always offer food/fluids by mouth if feasible and desired. [] No artificial nutrition [] Defined trial period of artificial nutrition [] Long-term artificial nutrition Oral fluids and nutrition should always be offered if medically feasible and if they meet the goals of care determined by the person or surrogate. The administration of nutrition and hydration whether orally or by invasive means shall be within the context of the person’s wishes, religion and cultural beliefs.

Section D – Cardiopulmonary Resuscitation and Airway Management CPR: Person has no pulse and/or is not breathing []Attempt resuscitation/CPR []Do not attempt resuscitation/DNAR Allow Natural Death AIRWAY MANAGEMENT Person is in respiratory distress with a pulse []Intubate/use artificial ventilation as needed []Do not intubate - Use O2, manual treatment to relieve obstruction, medications for comfort

Section E – Decision Making Capacity If I lose my decision-making capacity, I authorize my surrogate decision maker, listed below, to modify or revoke the NJ POLST orders in consultation with my treating physician/APN. [] Yes [] No Print name of Surrogate/Phone number NOTE: This section is applicable in situations where the person has decision making capacity when the POLST form is completed. A surrogate may ONLY void or modify an existing POLST form, or execute a new one, if named in this section by the person.

Section F - Signatures I have discussed this information with my physician/APN. Signature___________________________________ []Person Named Above []Health Care Representative/Legal Guardian []Spouse/Civil Union Partner []Parent of Minor []Other Surrogate____________________________

Section F continued Anatomical Gift – has person named above made an anatomical gift: []yes []no []unknown These orders are consistent with the person’s medical condition, known preferences and best known information. PRINT: Physician/APN Name, Phone Number Physician/APN Signature: (Mandatory) Date/Time

POLST in Summary Practitioner Orders for Life Sustaining Treatments Actionable medical orders that must be honored at point of contact with by EMS, ED, hospital, etc. Portable across all settings. Does not require a loss of decision-making capacity for it to go into effect. Legally sufficient and recognized as a medical order. POLST forms are green, to promote recognizability.

Meridian Health: For emergency room patients (on all initial assessments) Inquire about the existence of a POLST form. Make physician in charge of the patient at the time aware of the existence of a POLST form, as they will need to review it and determine if any new orders are indicated. In notifying the physician about the existence of the POLST, discuss the orders contained within it. Document the existence of the POLST and your communication of it to the physician or LIP (Licensed Independent Practitioner) Honor the POLST unless new medical orders dictate otherwise. Make a copy of the POLST (both sides) and place in the medical record orders section. Place a patient identifying label on the copy document and write COPY on the copied form with the date copied. Keep the original POLST in the medical records section as well, returning that original to the patient upon their discharge. Physicians/LIPs are expected to document the reasons for deviation from the POLST in the medical record after discussing the changes with the patient. In all communication handoffs, especially if the patient is admitted, communicate the existence of the POLST form.

Meridian Health: For admitted patients (on all initial assessments) Make physician in charge of the patient at the time aware of the existence of a POLST form, as they will need to review it and determine if any new orders are indicated. In notifying the physician about the existence of the POLST, discuss the orders contained within it. Document the existence of POLST and your communication of it to the attending physician or LIP The POLST form (legally actionable medical orders) is in effect until the physician/LIP is able to reassess the patient more fully and determine with the patient if any changes to the document are necessary. In the absence of any other orders, POLST provisions for care, including DNR, are in effect. Make a copy of the POLST (both sides) and place in the medical record orders section. Place a patient identifying label on the copy document and write COPY on the copied form with the date copied. Keep the original POLST in the medical records section as well, returning that original to the patient upon their discharge. Upon physician/LIP review and assessment, any hospital required forms, such as DNR orders, will be completed to complement POLST intentions. Upon discharge, if the POLST has been updated, send the most current original with the patient during any transfers or discharge to home. The physician/LIP should void the old POLST, by drawing a line through sections A through D and writing VOID in large letters on it. Document that the POLST form accompanied the patient on discharge/transfer. In all communication handoffs, especially to the EMS personnel on discharge, communicate the existence of the POLST.

POLST questions The POLST is a legal document. True False The POLST form includes: Goals of treatment Preferences related to CPR, intubation and mechanical respiration Preferences for artificial nutrition and hydration All of the above The POLST is transferable across all settings. True False The Nurse must copy the POLST and make physician in charge of the patient at that time, aware of the existence of a POLST form. True False POLST should be initiated by Physician or Advanced Practice Nurse when the person is diagnosed with advanced disease or frailty. True False