2. POST…. Physician Orders for Scope of Treatment 1 Respecting Patients’ Wishes at the End of Life Brandon Oaks Brandon Oaks Staff Training

3. 2 An Index Case Mr. Jan, a 71-year-old male with severe COPD and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing SOB and decreasing LOC over 24 hours. The nursing facility staff called EMS who found the patient unresponsive, with a RR of 8 and an O 2 sat at 85% on room air. Although Mr. Jan had discussed his desire to forgo aggressive, life-sustaining measures with his family and nursing personnel, the nursing facility staff did not document his preferences, inform the emergency team about them, or mention his do-not-resuscitate order.

4. 3 After EMS was unable to intubate him at the scene, they inserted an oral airway, bagged, and transported the patient to the emergency department (2 nd hospital). Mr. Jan remained unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P of 105, RR of 8, and an O 2 sat of 88% despite supplemental oxygen. He had diminished breath sounds without wheezes, and a chest X-ray showed large lung volumes without consolidation. Arterial blood gases showed marked respiratory acidosis. The emergency department physician wrote, “full code for now, status unclear.” The staff intubated and sedated Mr. Jan and transferred him to the intensive care unit. Lynn, et al. Ann Intern Med 2003;138:812-818.

5. What went wrong? (Could this happen in Roanoke?) Advance directives not documented DNR order not communicated in transfer Fragmentation in care (2 hospitals) Overtreatment against patient’s wishes Unnecessary pain and suffering System-wide failure to respect pt’s wishes – Failure to plan ahead for contingencies – No system for transfer of plan 4

6. What is POST? A physician order Can be completed by a non-physician provider but must be signed by qualified MD or DO (Osteopath) or NP or PA allowed to sign under their practice agreement. Complements, but does not replace, advance directives Voluntary use Recognized by EMS as a valid DDNR 5

7. POST is for… Seriously ill patients* Terminally ill patients 6 * chronic, progressive disease/s

8. Purpose of POST To provide a mechanism to communicate patients’ preferences for end-of-life treatment across treatment settings To improve implementation of advance care planning 7

9. Expected Outcomes of Using POST Process Improved continuity of care—Form transferable across treatment settings Clearer communication of wishes Reduced hospitalization and inappropriate life-sustaining treatments – Fewer EMS transports More accurate representation of preferences Higher adherence to wishes by medical professionals.

10. Conversations that change over time Source: Carol Wilson, Riverside Health System; Used with permission Healthy Adults: Emergency Planning People with Progressive Illness: guided planning End Stage Illness: Physician Orders for Scope of Treatment

11. Living Will* v. POST Living Will For every adult Requires decisions about myriad of future treatments Clear statement of preferences Needs to be retrieved Requires interpretation POST For the seriously ill Decisions among presented options Checking of preferred boxes Stays with the patient A physician’s order to be followed 10 *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42.

12. Why POST Works… MUST accompany patient Contains specifics Physician’s order—no interpretation is needed – POST orders are to be followed 11

13. Prompt for POST Completion 12 Would you be surprised if this patient died in the next year?

14. POST: Who Should Have One? Anyone choosing “Do Not Resuscitate” Anyone choosing to limit medical interventions Anyone eligible/residing in a LTC facility Anyone who might die within the next year

15. Communication across Settings The health care facility initiating the transfer shall communicate the existence of the POST form to the receiving facility prior to the transfer. The POST form shall accompany the person to the receiving facility and shall remain in effect. POST Project Policy and Procedure 14

16. POST Can Be Completed In Many Settings

17. Let’s Review True/False – If a patient has a living will they don’t need a POST form.

18. Let’s Review False. A living will is a more generalized statement of wishes. A POST is physicians orders for specific care wishes of the resident and these orders must be followed

19. Let’s Review Which residents are candidates for completing a POST form?

20. Let’s Review A POST form is appropriate for residents who – Are terminally ill – Are seriously ill with a progressive, chronic disease – Are not expected to live more than a year

21. Developing Programs National POLST Paradigm Programs Endorsed Programs No Program (Contacts) *As of February 2013

22. POST Pilot Project POST orders legally recognized in several states, including West Virginia. Roanoke Valley is a POST Pilot Project Region Plan to make POST a legal document recognized throughout Virginia

23. Who is Participating in the Pilot? Palliative Care Partnership of the Roanoke Valley Friendship Health and Rehab Center Richfield Recovery and Care Center Brandon Oaks Carilion Clinic: Roanoke Memorial Hospital Lewis-Gale Medical Center (coming on board) Hospice patients in the following hospices: Good Samaritan Hospice; Carilion Clinic Hospice

24. EMS Participants Roanoke County Fire & Rescue Roanoke City Fire & EMS Salem Fire & EMS Local medical transport companies – Carilion Clinic Patient Transport – Life Care – United – Guardian – Others

25. POST Form

26. The POST Form 25

27. 26

28. Section A: Resuscitation DNR orders only apply if a person has no pulse and is not breathing Note: This section has 2 choices: Attempt Resuscitation and Do Not Attempt Resuscitation: Check to see which box is checked! POST Section A recognized as a valid Virginia Other DNR. When Do Not Attempt Resuscitation is checked, qualified healthcare personnel are authorized to honor this order as if it were a Durable DNR order OEMS approval (Michael Berg) 27

29. Section B: Medical Interventions If in the “terminal” phase, POST and advance directive should be consistent Care plan should always be consistent with POST If Comfort Measures are selected consider hospice consultation 28

30. Levels of Medical Interventions Comfort Measures – Treat with dignity and respect. – Keep warm and dry. – Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. – Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. – Transfer to hospital only if comfort needs cannot be met in current location. Also see “Other Instructions” if indicated below. 29

31. Levels of Medical Interventions Limited Additional Interventions – Include comfort measures. – Do not use intubation or mechanical ventilation. May consider less invasive airway support (e.g., CPAP or BiPAP). – Use additional medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. – Hospital transfer if indicated. Avoid intensive care unit. Also see “Other Instructions” if indicated below. Full Interventions – In addition to Comfort Measures above – use intubation, mechanical ventilation, cardioversion as indicated. – Transfer to hospital if indicated. Include intensive care unit. – Also see “Other Instructions” if indicated below. 30

32. Section C: Artificial Nutrition These orders pertain to a person who cannot take food by mouth Feeding tube for a defined trial period: Gives option to determine benefit to patient and/or recovery from stroke, etc. 31

33. POST Sections (Other)  Discussed with  Physician Signature and contact info  Patient/Authorized Decision Maker  Authority to sign patient if patient is incapacitated  Facility of POST form origin  Name and signature of Facilitator  Instructions 32

34. Original Form Shall Always Accompany Patient/Resident When Transferred or Discharged! 33 On the top of the transfer packet!

35. “Where is the POST form?” 34

36. At Transfer The yellow POST form placed in a red envelope with a label and placed at top of transfer documents: – “POST Order Form---This Form is to Accompany the Resident Upon Transfer or Discharge; if resident returns to (name of facility), please return this form to: (address of facility) EMS, hand this envelope to person in charge of receiving resident/patient transfer documents.

37. Let’s Review What color is the POST Form? True/False: In order for a POST form to be valid, it must be signed by an MD or DO licensed in Virginia True/False: EMS will not recognize the POST form as a valid DDNR

38. Let’s Review Section A of a resident’s POST form says he wishes to not be recussitated. Section B of a resident’s POST form indicates that the resident wants Comfort Measures. You find the resident unresponsive, has shallow respirations with long periods of apnea, and a pulse of 100. What should you do?

39. Let’s review As long as the resident’s comfort can be provided for at the facility, this resident is not to be transferred to the hospital. How would you handle it, if a family member were insisting that you send the resident to the hospital?

41. How to Complete a POST Form Must be completed by a physician or by a non-physician health care professional who has been trained as a POST Advance Care Planning Facilitator (ACPF). Must be based on patient/resident preferences Must be signed by an MD or DO; may be signed by an NP or PA if within their practice agreement.

42. Why an Advance Care Planning Facilitator (ACPF)?

43. Why an ACPF? Has received training in having discussions with patients and POA’s about preferences for EOL care Training was based on our POST form The Advance Care Planning process takes about 45 minutes and often involves follow-up and/or additional sessions It is important that POST form is not just a check off sheet---an ACPF can make sure people know and understand their options

44. Who are the Trained ACPF’s at Brandon Oaks? Dr. Soheir Boshra, MD Melissa Conner Kim Bain Jean Craddock Nancy Patterson

45. Steps to Starting POST Process For the Resident Identify residents who might be appropriate for POST process (due to condition, resident/POA request, or else resident is admitted with a POST form). Notify a POST ACPF that resident was admitted with a POST form or resident might need a POST form completed

46. Steps to POST Process Resident’s physician or ACPF completes POST Form (or reviews POST form that came with resident upon admission). – If ACPF completes, then physician notified that there is a POST form to sign.

47. Steps to POST Process Person completing POST Form: – Document in Interdisciplinary Notes and Plan of Care – Enter the orders into the active medical record consistent with those in the POST order set. – Make copy of POST form to give to the social worker and to the resident or their substitute decision maker. – Original of POST form goes in a clear plastic sleeve behind Advance Directives tag

48. Steps to POST Process Person completing POST form (continued): – Place yellow POST sticker on the front of chart: – Notify nursing unit charge nurse and social worker that POST has been signed and what those POST orders are – Review POST form with resident/POA periodically (at quarterly team meetings) and prn (i.e. when condition changes)

50. Transfer/Discharge Prior to discharge/transfer to another care setting, the resident’s nurse or social worker arranging the transfer will notify receiving facility by telephone call of POST form. Put original POST form into a labeled red envelope and place at top of transfer documents. Unit Manger or Charge Nurse: Make sure a photocopy of the current POST form is in Advance Directives section of the resident’s chart

51. Envelope Label ORIGINAL POST/DDNR Forms Enclosed Forms are to accompany Resident upon Discharge/Transfer PLEASE RETURN ORIGINAL FORM IN THIS ENVELOPE TO:

52. The Red Envelope for Transfer/Discharge

53. Let’s Review Where does the current original copy of the POST form go in the chart? Who may help a resident/POA complete a POST form? What do you do if a resident with a POST form is to be transferred to another health care setting or home with hospice care?

54. Let’s Review Upon transfer: – Call the receiving facility and notify of POST – Make sure a photocopy of POST form is in the Advance Directives section of the chart – Put original copy of POST form in labeled red envelope and put on top of transfer packet – Alert EMS/transporter of the POST form

55. Communicate, Communicate, Communicate! Make sure receiving care setting knows there’s a POST form. Make sure the EMS or transport personnel know that there is a POST form and show them where it is. Ask EMS/transporter to point out POST form to person receiving the resident. When resident returns, ask “Where’s the POST Form?”!!!!!!

56. Resident Dies at Brandon Oaks If the resident dies at Brandon Oaks, the original POST form is to be placed in the Advance Directives section of the closed medical record by Medical Records.

57. Resident is Admitted with a POST Admissions: Notify receiving unit of POST Unit Support: Place the original in a clear plastic sleeve in the Advance Care Planning section of the chart. Notify PCP and POST Advance Care Planning Facilitator. PCP or ACPF: – Review the POST form with the resident; – Enter orders consistent with those in the POST form.

58. Revoking/Making Changes to POST If the resident wishes to change the POST form, the original POST form shall be voided, and a new one completed.

59. Revoking/Changing a POST Form To change POST, the current POST form must be voided and a new POST form completed. If no new form is completed, full treatment and resuscitation may be provided. As long as the patient can make his/her own decisions, then the patient can revoke consent for POST and also may request changes to POST.

60. Revoking/Making Changes to POST If a patient tells a healthcare professional that he wishes to revoke his consent to POST or change POST, the healthcare professional caring for the patient should draw a line through the front of the form and write “VOID” in large letters on the original, with the date and their signature, and notify the patient’s physician. A new POST form then may be completed if desired by the patient. The physician or a POST ACPF may complete the new form.

61. Revoking/Changing POST If “Do Not Attempt Resuscitation” is checked in Section A and the patient has signed this form, no one has the authority to revoke consent for the DDNR order other than the patient as stated in the Code of Virginia section 54.1-2987.1.

62. Revoking/Changing POST If the patient signs this form, then the patient’s overall treatment goals should be honored if the patient later becomes unable to make decisions. If the patient is unable to make healthcare decisions, a legally authorized medical decision maker, in consultation with the treating physician, may sign this form, revoke consent to, or request changes to the POST orders (except in section A as noted above) to continue carrying out the patient’s own preferences in light of changes in the patient’s condition.

63. Revoking/Changing POST – The voided POST form shall be placed in the Advance Directives section of the thinned chart.

64. Who Does What? Let’s review.

65. Questions?

66. Everyone! (Whether Medical, Nursing, Social Services, Admissions or MDS) Keep your eyes and ears open to residents who might need ACP and a POST form

67. Take-Home Messages POST provides a better means than AD to identify and respect patients’ wishes POST completion will improve end-of-life care throughout the system Use of POST will require communication to make it work in your community Know your role. “Where’s the POST form?” 66