Physician Orders for Life-Sustaining Treatment Information for Emergency Medical Services, Physicians and Hospital Staff

Physician Orders for Life-Sustaining Treatment (POLST) Objectives:  Review the history of POLST and current National POLST Paradigm Programs  Identify the similarities and differences between POLST and other advance directives  Review pertinent NV POLST legislation  Identify the unique features of NV POLST and where healthcare providers can locate the NV POLST forms  Review that POLST is honored in any healthcare setting and in the field by healthcare providers and by Emergency Medical Services

Physician Orders for Life-Sustaining Treatment (POLST) Objectives (continued) :  Review physician responsibility regarding initiating NV POLST  Identify when POLST forms may be revised or revoked  Review when POLST conflicts with other advance directives  Review the healthcare provider’s responsibilities when a patient with a POLST form is discharged

Physician Orders for Life-Sustaining Treatment (POLST) The National POLST Paradigm originated in Oregon in 1991 POLST creators found that traditional advance directives were vague, too long, and were difficult to locate The newly created POLST forms succinctly identified patient wishes, were easily identifiable, described specific treatments, were portable from one setting to another and were enacted only after the patient and physician had a meaningful discussion about options and patient wishes for end of life care. (Source:

POLST Paradigm (as of December 2013)

Nevada POLST

The Nevada Legislature unanimously approved POLST and the law went into effect October 1, (AB344) The Nevada POLST Coalition developed a POLST form and the Nevada Board of Health approved a state-wide POLST form in January Winter 2013-Spring 2014: The Nevada POLST Coalition and the Nevada Hospital Association developed education and tools for physicians, hospital staff, and emergency medical services staff, as well as developed media releases to promote POLST to Nevada’s communities.

POLST & Advance Directive Similarities Both documents: Are based on values and are initiated after conversations are held with the patient and loved ones. Are based on patient wishes, medical orders and a promise by healthcare providers to honor these wishes. Address comfort measures Are only invoked when the patient is unable to express treatment wishes themselves.

POLST & Advance Directive Differences The POLST form is concise and provides directions to healthcare providers on the specific treatment desired by the patient after they have discussed their options with their physician POLST is introduced by physicians when they are caring for: frail elderly patients, or those patients with serious, advanced, progressive diseases Patients with a 5 year life expectancy or less A patient may also request a POLST discussion and completion of a POLST form

POLST & Advance Directive Differences (cont’d) POLST reflects the patient’s current state of health POLST travels with the patient to any setting, including their residence or while transporting from one setting to another It provides for an out-of-hospital DNR to be honored by Emergency Medical Services (EMS) It requires a physician signature and date The form must be signed by the patient or legal representative who held the discussion with the physician

Nevada POLST Features Should be printed on hot pink stock paper (if available) POLST Patient FacilityEMS ASK

Nevada POLST Features The POLST form is available at many sites: Nevada State Medical Society website: nsma.org Secretary of State: LivingwillLockbox.org Nevada State EMS: http//health.nv.gov/PDFs/EMS/Forms/POLST form At Sunrise Hospital: Forms Fast under the ADM or CM Cabinets

Nevada POLST Side One: Medical Orders Instructions Patient Information CPR Other medical interventions Physician documentation

Nevada POLST Side One: Medical Orders Instructions & Patient Information

Nevada POLST Side One: Medical Orders Section A: CPR The EMS- DNR # from the salmon-colored card is no longer necessary: Because the legislature approved POLST to be honored across all settings Unless someone wants to use it when away from their residence

Nevada POLST Side One: Medical Orders Section B: Interventions & Comfort Measures This section is relevant if: “Attempt Resuscitation” (CPR) is checked/marked in Section A,or The patient is not in cardiopulmonary arrest If checked, the patient should remain at their current location (home, nursing home, etc.) unless comfort cannot be achieved at this location.

Nevada POLST Side One: Medical Orders Section B: Interventions > Antibiotics, Fluids & Nutrition

Nevada POLST Side One: Medical Orders Section B: Interventions > Limited versus full treatment

Nevada POLST Side One: Medical Orders Section C: Physician Validation To be valid, the Nevada POLST form must be signed and dated by both the physician and the patient or their legal representative. The Physician signs in Section C

Nevada POLST Side One: Medical Orders Section F: Signatures To be valid, the Nevada POLST form must be signed and dated by both the physician and the patient or their legal representative. The Patient or their representative signs the first line of Section F

Nevada POLST Side Two: Patient Preferences Organ Donation AD Information: Summary of information in patient’s Living Will, Declaration and/or Durable Power of Attorney (DPOA) Patient/Physician conversation information LivingWillLockbox.com information General Instructions

Nevada POLST Side Two: Patient Preferences Section D: Organ Donation Verify patient’s name and date of birth with their patient identification bracelet (if the patient is in a hospital or similar facility) Organ Donation: Checking this box does NOT give authorization for organ donation. Check the patient’s NV state-issued ID to verify.

Nevada POLST Side Two: Patient Preferences Section E: Advance Directive Summary If the patient’s Advance Directive (AD) is available, this section should be completed. If the patient has their AD registered with the Nevada Living Will Lockbox, they may have the Lockbox ID available.

Nevada POLST Side Two: Patient Preferences Section E: Advance Directive Summary If a patient does not have a Durable Power of Attorney for Health Care, then NRS defines an order of authority to represent the patient (spouse, adult children, parents, siblings, other relatives in that order).

Nevada POLST Side Two: Patient Preferences Section F: Signatures The patient or their legal representative (Agent/DPOA, Parent of a minor or legal guardian) MUST sign the first line and date it An agent is the patient’ Durable Power of Attorney (DPOA) for Healthcare The second signature line is for anyone who witnessed the conversation (not required, but helpful) The last two lines are for whoever prepared (had the conversation)with the patient or their representative. They print, sign and date. Also not required, but hlepful.

Nevada POLST Side Two: Patient Preferences Section G: Registry A POLST form may be registered with the Nevada Secretary of State’s Living Will Lock Box (LWL): Physician’s, physician office staff and hospital office staff may be granted access to the LWL Sunrise Hospital and several key staff are registered with LWL POLST and the LWL authorization should be completed at the same time with the patient then submitted to the LWL to assure state-wide access. The medical provider should also fax the POLST and Registration to the LWL when completed to assure its submission

Nevada POLST Law: A physician or other healthcare provider cannot be disciplined or face legal action if: Treatment is withheld in compliance with the POLST form and the medical orders reflected on it The provider is unaware of the existence of the patient’s POLST The patient, their agent, parent (if a minor) or legal guardian over-rides it

Nevada POLST Law: Physician Authority and Privileges Healthcare providers shall comply with a valid POLST regardless of whether the physician who signed the POLST: Has authority during transport, or Has privileges at the receiving facility

Nevada POLST Law: Physician Responsibility A POLST should be completed for the patient if: Their life expectance is less than 5 years They have a terminal illness They request one In these instances, the physician shall explain: The availability of the POLST The feature and procedures offered by it The differences between the POLST and other Advance Directives

Nevada POLST Law: Reviewing and Revising the POLST A POLST should be reviewed when the patient: Is transferred from one care setting or level to another Has a substantial change in health status The patient’s preferences change When a POLST needs to be revised due to wear/tear or change of orders/information, the physician and patient should: Write VOID diagonally across both sides of the POLST and place in the patient’s chart Complete a new POLST, sign, and date it

Nevada POLST Law: Conflicting Documents Should an Advanced Directive and POLST conflict, the AD takes precedent If a patient has both a POLST and a valid DNR identification, regardless of the dates, the DNR is to be followed.

Nevada POLST Law: Compliance Should a physician or other healthcare provider be unwilling to comply with the directives of the POLST, all reasonable measures shall be taken to transfer to a compliant provider or facility If a patient is known to be pregnant, so long as it is probable that the fetus will develop to the point of live birth with the application of life-sustaining treatment, life sustaining measures shall be attempted

Nevada POLST: Miscellaneous Any completed section is valid unless the POLST is not signed and dated by a physician Blank sections should be presumed to indicate full treatment, unless it conflicts with a completed section The POLST (MOST, POST, MOLST) of another state shall be honored in Nevada

Sunrise Hospital POLST forms are available in Forms Fast Upon discharge, the original POLST form is to be given to the patient if they are discharged home or in the transfer packet, if they are discharged to a facility A copy of the POLST form remains with the patient’s medical record Sunrise Hospital has a Policy: Physician Orders for Life Sustaining Treatment (POLST)

References Nevada POLST Many thanks to Sally Hardwick, MS with the Nevada POLST Coalition for creating and editing this presentation.