1. I NTRO TO I LLINOIS ’ S NEW IDPH UNIFORM DNR A DVANCE D IRECTIVE POLST Physician Orders for Life-Sustaining Treatment Presented for Long Term Care by:

2. Meet Hobart Hobart is 87 years-old and went to live in a nursing home after his wife died three years ago. He just got back from the hospital where he was admitted for four days and treated for a serious infection He tells you how much he hates going to the hospital and he doesn’t want to do that again

3. Hobart’s Rights Hobart has the right to say what care he wants, and also what medical treatments he doesn’t want As a caregiver, you want to make sure that he gets every medical treatment he wants, but also that he is not forced to receive treatments he does not want

4. Making Good Plans for Hobart Hobart’s daughter knows his wishes, but his daughter lives in another city and works a very busy job. Sometimes Hobart’s daughter doesn’t immediately answer her cell phone, even though she always returns your calls at some point

5. Making Good Plans for Hobart You know that sometimes residents can get sick fast. Hobart may develop another infection, or it can be an emergency like a heart attack or the inability to breathe on his own How do we make plans to guide us in an emergency?

6. What Options Do You Have? The first step many people take when they want to make sure their wishes about medical treatment are honored even when they can’t make their own decisions is an Advance Directive The most common Advance Directive is a Power of Attorney for HealthCare

7. A Power of Attorney (PoA) is a Person Who Can Make Medical Decisions The Power of Attorney for Healthcare tells you who should make medical decisions for Hobart if he can’t make those decisions for himself This is a good option, but his daughter has to be contacted by phone, and during an emergency like a heart attack, every second counts Is there something that addresses emergency medical treatment?

8. POLST A good Advance Directive that can tell you what Hobart wants in an emergency is an Advance Directive called POLST POLST stands for Physician Orders for Life Sustaining Treatment

9. POLST for Hobart POLST tells everyone taking care of Hobart what his wishes are in case of a life- threatening emergency The use of the POLST form is consistent with CMS regulations

10. Hobart’s Wishes During an Emergency Hobart tells his doctor that he wants to be treated for infections and pain, but if his condition is so serious that he needs life-support, he does not want that. He would rather stay at the nursing home and just be made comfortable.

11. POLST Provides Medical Orders Now we have to find out which POLST options best fit Hobart’s wishes POLST has five sections, but you probably only need to know about two of those sections

12. 2 Emergency Medical Order Sections A.CPR for Full Arrest Yes, Attempt CPR No, Do Not Attempt CPR (DNR) B.Orders for Pre-Arrest Emergency Full Treatment Limited Treatment Comfort Only 12 The POLST Document

13. Section A and Section B Section A: should you do CPR if the resident stops breathing and has no pulse? Section B: how aggressive should the treatment be if the resident has a life- threatening emergency but is still breathing?

14. Relieve Suffering Always It does not matter what options a resident chooses – he or she should always be medically evaluated and provided with pain relief and relief of any suffering Other wishes, like calling family members or a clergy person should also be followed

15. Section “A”: Cardio-Pulmonary Resuscitation 15 Code Status – applies when breathing AND pulse have stopped 15 If the person chooses “Attempt Resuscitation” you do NOT need to look at any other box on this form. Start CPR and “Go.” If the person checks “DNR” and is in full arrest, “Stop” and do not begin CPR.

16. Section A: Full Cardiac Arrest There are 2 options in Section A – Yes, please try CPR to resuscitate me – No, if you find that I have died, please do not try to bring me back If Hobart chooses CPR it may or may not work, but we will try everything, including calling 911 If Hobart chooses no CPR, his body will be treated with dignity and his family will be called

17. Would Hobart Choose CPR? Hobart accepts that he is coming to the end of his life. He says to his doctor “if it is my time to go, I don’t want you to try to bring me back. Just let me go.” Hobart would choose DNR for full arrest.

18. Section B: Emergencies when the resident is still alive The next section, Section B, talks about emergencies like a heart attack or difficulty breathing where the resident is still alive but is in danger of dying if immediate action isn’t taken

19. Section “B”: Medical Interventions 19 If the patient is still breathing or has a pulse, how aggressive should our treatments be? Comfort – patient prefers to stay at the facility and be made comfortable, Limited – patient wants basic treatments but not life-support Full – patient wants everything done 17 Do Not Resuscitate does NOT mean Do Nothing

20. Section “B”: Medical Interventions 20 If the resident chooses the first category of comfort only, in red, you should consider what you can do to make them as comfortable as possible in their own bed. Comfort treatment is still treatment, you just try to do maximize the care the person receives without sending them to the hospital. Talk to the nursing supervisor or the patient’s doctor to get them the care they need. If the person has care needs that can not be met in their own bed, you may still need to send them to the hospital. The relief of any pain and suffering is your highest goal. 19

21. Section “B”: Medical Interventions 21 If the resident chooses Limited treatment, in yellow, you should still move quickly to get them the care the need, but you need to proceed with caution because the patient has said there are some treatments they do not want. You can think of this section like a stoplight. If the resident chooses the last category of full treatment, in green, you should quickly “go” and get them all the care they need, including going to the hospital. 19

22. Would Hobart Choose Comfort Only? The option of Comfort Only on the POLST form in Section B is for those residents who, at the end of their life, do not want any more hospital medical care and just want to be made as comfortable as possible in their own bed This does not sound like what Hobart wants

23. Limited Treatment – Still Treatment, But Does Not Include Life-Support The second option in Section B is Limited Treatment. This option says that the resident wants to be treated for medical problems, but doesn’t want to be put on life-support, even if it is needed to keep him from dying This sounds like the option Hobart would want to choose. He will still go to the hospital, but he will not have to be on life-support

24. Would Hobart Choose Full Treatment? The last option under Section B is “Full Treatment” which includes life-support (that is why it says Intubation and Mechanical Ventilation which involves a machine to help him breathe). If he chooses “Full Treatment” he will be put on life-support if he needs it. At any time, Hobart can change his mind and ask for all medical treatments that can be offered.

25. Section C: Feeding Tubes The next section, Section C, is really for doctors. It tells healthcare providers if the resident wants an artificial feeding tube to provide nutrition if the resident is not able to eat enough food by mouth. Often times, a person who is in the final stage of life can no longer process the nutrition, or they may not want a feeding tube.

26. Food by Mouth Residents should always be offered food by mouth as they desire or as is medically feasible. Careful hand-feeding has been shown to be as effective as feeding tubes for some residents at the end-of-life. If a resident has chosen DNR- Comfort, staff may want to consider offering the resident the food of the resident’s choice.

27. What Should I Do With The POLST? It is important that the POLST document be immediately available during an emergency where every second counts Your institution should decide on an easy to find location that is the same for every resident You also want to choose a location that still protects the resident’s privacy regarding their healthcare choices

28. NO. It is recommended that the form be printed on pink paper – this is only to make it easier to see The original pink form should stay with the resident at all times, especially when they transfer However, all copies of the form are valid, regardless of color 28 Does the Color of the Form Matter?

29. Requirements to Make the Form Valid Patient/Resident name Resuscitation orders (Section “A”) Signatures – Patient/Resident or Legal Representative signature – Witness signature – Provider signature, name, and date (this makes it medical order that has to be followed by everyone) All other information is optional 29 3 Signatures are Required

30. This presentation for the POLST Illinois Taskforce has been made possible by in-kind and other resources provided by:

31. THANK YOU! Original presentation developed by Kelly Armstrong, PhD for the Illinois POLST Taskforce. Contact: karmstrong@siumed.edu