POLST and Hospice An Update for Oregon Gary Plant MD FAAFP Madras Medical Group Oregon POLST Task Force Oregon Academy of Family Physicians

Patient-Centered Primary Care Institute Online Modules Webinars Website Learning Collaboratives Trainings TA Network

Learning Objectives By the end of the workshop, the learner will: Understand who should have a POLST form Understand how to complete and sign a POLST Know what to do with the completed POLST Recognize the POLST as a tool for clarifying the patient’s wishes for end-of-life care

What is POLST? Physician Orders for Life Sustaining Treatment A tool for clarifying the patient’s wishes for care at the end of life Legal orders that can be followed by emergency personnel to provide only the care desired by the unresponsive patient

New Registrants by County: 2014 Includes only registrants that provided address information and reside in Oregon New Registrants Mapped 22, 047 (71.6%) New Registrants Unmapped 8,742 (28.4%) Total 30,789

Proportion of County Population over age 65 with Active POLST in Registry 5/3/09-12/31/14 Data as of 1/12/15 Includes only registrants that provided address information and reside in Oregon New Registrants Mapped 74,176 (64%) New Registrants Unmapped 41,715 (36%) Total 115,901

POLST Is Changing the National Paradigm

Who Should Have a POLST Form?

Who Should Have a POLST? If you would not be surprised by the patient’s death within the next year, consider completing a POLST Elderly, frail, declining Terminal disease at any age Adamantly declines resuscitation at any age

How Advanced Directives and POLST Work Together Age 18 Complete an Advance Directive Update Advance Directive Periodically Diagnosed with Advanced Illness or Frailty(at any age) Complete a POLST Form Change in health status May Complete a new POLST Form Treatment Wishes Honored

Oregon 2014 POLST form

Section A: Cardiopulmonary Resuscitation Patient is unresponsive, pulseless, and not breathing Attempt resuscitation (CPR) or not (DNR) Required for submission to registry

Oregon 2014 POLST form Section B: Medical Interventions Patient has pulse and is breathing Clarifies the level of intervention desired by the patient

Oregon 2014 POLST form Section B: Medical Interventions Comfort Measures Only: focus on relief of pain and suffering (most common for Hospice) Limited Treatment: treat easily corrected problems with medications, fluids, etc (may be appropriate for some Hospice patients) Full Treatment: focus on prolonging life through all available measures (typically not appropriate for Hospice)

Section C: Artificially Administered Nutrition Always offer food and drink by mouth if feasible Long-term artificial nutrition is typically not appropriate for Hospice patients Most patients choose no artificial nutrition Defined trial period of artificial nutrition may be appropriate in limited Hospice situations Oregon 2014 POLST form

Section D: Documentation of Discussion If the patient is unable to have a meaningful discussion of end-of-life wishes, document with whom you spoke to determine those wishes Oregon 2014 POLST form

It is recommended (but not required) to have the patient or their surrogate sign the form to acknowledge their participation in the process The 2014 POLST has an optional box to opt out of the POLST registry if the patient does not want their POLST submitted Opting out of the registry greatly reduces the benefit of completing the POLST Oregon 2014 POLST form

Oregon Law allows a POLST to be signed by an allopathic or osteopathic physician, a nurse practitioner, or a physician assistant A valid POLST includes the printed name of the signing clinician, the signature, and the date that the form was signed Oregon 2014 POLST form

What Happens Next with the POLST? A completed POLST should be submitted to the Oregon POLST registry Electronic submission may be coming soon, but currently a copy of the form must be faxed or mailed to the registry A copy of the completed POLST should be included in the medical record The original POLST goes with the patient to their home or accepting facility

Once entered in the Oregon POLST Registry, the patient will receive a letter in the mail including: A description of their answers to sections A, B, and C for validation A sticker with their registry number to place on the original POLST form A refrigerator magnet with their POLST registry number What Happens Next with the POLST?

How Does It Work? Scenario 1 EMT’s respond to a 911 call and find an unresponsive patient who is pulseless and not breathing. The patient has a POLST indicating no resuscitation. The patient’s wishes are honored. If the POLST is not immediately available, EMT’s would begin resuscitation while contacting the POLST registry. If the registry has a POLST indicating no resuscitation, CPR would cease.

Scenario 2 A patient on Hospice is actively dying and unable to communicate verbally, but is moaning and writhing due to uncontrolled pain and has started having occasional seizures. The decision is made to transfer to the hospital for symptom management. The POLST indicates DNR, comfort measures, and no artificial nutrition. What constitutes “comfort measures”? How Does It Work?

Questions?

Special Thanks To… Patient-Centered Primary Care Institute Oregon POLST Task Force Oregon Academy of Family Physicians Oregon Hospice Association And all of you for participating!!