Introduction to IPOST “Iowa Physician Orders for Scope of Treatment” Francis Dominic Degnin M.P.M., Ph.D. Associate Professor, UNI Department of Philosophy & World Religions Clinical Ethicist Wheaton Franciscan Health Care of Iowa

Primary Resource The State of Iowa IPOLST Web page http://www.idph.state.ia.us/IPOST/Defaul t.aspx Many slides come directly from this site. Primary Resource

Originally part of the POLST (Physician Orders for Life Sustaining Treatment) project, IPOLST was first piloted in in Iowa in 2008. It was signed into Law and took effect statewide on July 1st, 2012. POLST forms are used, either in pilot or final form, in over half the states. History

General: Like all advanced directives, IPOLST is intended to help ensure that patient’s health care wishes are honored. Specific: IPOLST attempts to provide actionable details for EMTs and ERs in emergency situations. IPOLST attempts to address an identified problem that many providers use resuscitation status to entirely determine the level of treatment—either comfort measures or full code. IPOSLT allows patients a greater range of treatments between these two extremes. Purpose

1-page, 2-sided form based on the national POLST movement that consolidates and summarizes patient preferences for key life- sustaining treatments including: CPR, general scope of treatment, artificial nutrition on a standardized, clearly identifiable form. IPOST complements advance directives by translating patient treatment choices into actionable medical orders which can be relied upon across all care settings. It is primarily intended to be used by: • the chronically, seriously ill individual in frequent contact with health care providers • an individual with a life-limiting illness • the frail and elderly (Palliative Care PP 16) What is IPOLST?

IPOLST Forms Are one page, two sided, salmon colored. Cannot be reproduced or modified by health care institutions. Patients can include additional instructions. Can be copied once filled out. A copy or a fax is equally valid, even if on standard paper. Changes made to an existing IPOLST require a new form. IPOLST Forms

Operations and Evaluation IPOST at front of patient’s medical chart IPOST transfers with patient from one healthcare setting to another including to and from home Update or void IPOST when the patient’s treatment choices change or substantial change in person’s health status Regular review of IPOST at quarterly care conferences in facilities or physician appointments Data collection to determine implementation rate and effectiveness IPOST belongs to the patient (Pal Care PP 21) Operations and Evaluation

IPOLST and other Advanced Directives? IPOLST may replace a Living Will, but it should not a Durable Power of Attorney for Health Care. If there is a conflict between IPOLST and the two more traditional advanced directives, Iowa Law specifies that IPOLST is secondary. ? This may be a meaningless distinction, because the real issue is to get at the patient’s wishes, not to blindly follow a set of rules. If it becomes clear to us that IPOLST better expresses a patient’s wishes, the Cruzan 1990 would trump state law. IPOLST and other Advanced Directives?

The provider fills out the form in conversation with the patient or surrogate. The state offers training on these provider-patient discussions. The Patient or Surrogate must sign the form. One of the following must also print, date, and sign: Physician Nurse Practitioner Physician’s Assistant A phone in order is acceptable so long as it is later signed by the provider. Filling out IPOLST

Any section not filled out implies full treatment in that section. A semi-automatic external defibrillator should not be used for a DNR patient unless otherwise specified. Allows for deactivation of an internal defibrillator if comfort only measures are in effect. Comfort medications by alternative routes or administration are compatible with comfort only measures. (IPOST Form pg 2) Using IPOLST

Revoking an IPOSLT Form (In hospital) Draw a line through sections A-C and write VIOD over these sections. Sign and date. Fill out a new IPOSLT if appropriate. If released to a care facility, return both the old and the new forms with the patient. The care facility will destroy the old form. If released home, the hospital destroys the old form and sends the new form home with the patient. Revoking an IPOSLT Form (In hospital)

IPOST Strengths (identified by evaluation) Converts patient preferences into immediately actionable medical orders readily accessible to medical personnel, including EMTs IPOST alters treatment: The presence of the IPOST changed the treatment that the healthcare provider would have given if patient did not have IPOST Treatment changes included: comfort measures only, type of resuscitation, no intubation and no intravenous line started IPOST addresses a misconception: Healthcare providers are often under the assumption that patients either want the maximum or minimum level of care across all end-of-life treatment options. Our medical chart review and several studies have shown that the majority of patients want different levels of end-of-life treatment IPOST addresses this misconception by documenting the type of treatments the patient wants regarding resuscitation, medical intervention and nutrition Positive staff, facilitator and patient/family experiences (Overview PP 12) IPOST Strengths (identified by evaluation)

Healthcare Provider Survey Was treatment altered to respect patient choices based on having an IPOST available? 28% (n=16) surveyed indicated IPOST form altered treatment Most frequent treatment altered was Comfort Measures Only. • 33% indicated treatment would have been more aggressive without IPOST Second most frequent treatment altered was Type of Resuscitation. • 22% indicated CPR/Attempted Resuscitation was reevaluated due to presence of IPOST No Intubation (19%), No Intravenous Line started (15%), and Increased Level of Treatment (11%) were also indicated by those surveyed that these treatments were altered based on the IPOST (Palliative Care PP 24) Healthcare Provider Survey

Healthcare Provider Survey What do healthcare providers think about IPOST? 90% wished more patients in the area had IPOST forms, the other 10% were neutral 92% agreed that the IPOST form provides clear instructions about patient’s preferences 87% feel more comfortable knowing what to do when an IPOST form is available 80% agreed that the IPOST form has made more difficult decisions easier (Pal Care PP 24) Healthcare Provider Survey