1. You’ve Got Questions? We’ve Got Answers Sally Hardwick, MS Chair, Nevada POLST – A Nevada Non-Profit Providers Training

2. In the Beginning POLST: Physician’s Order for Life-Sustaining Treatment Oregon POLST – 1991 Advance Directives (ADs) provided general guidelines, but specifics were still vague ADs are difficult to locate Too long

3. The Oregon POLST Meaningful Conversation of patient wishes and treatment ramifications Succinctly identifies patient wishes Easily identifiable More specific treatments Portable medical orders Intended redundancy

5. Similarity to ADs Thoughtful, considered conversation with patient and loved ones Based on values Comfort measures are always provided Only used when unable to express themselves

6. Differences between the Nevada POLST Program and Other ADs This is not just a form, it is a program involving a discussion between providers and patients and coordination between facilities and emergency medical services Frail, elderly or those with serious, advanced, progressive disease 5 year life expectancy Reflects current state of health Medical order that travels with the patient (home, transport or facility) Requires physician and patient or patient’s representative’s signature and date Provides for an out-of-hospital DNR (residence, transporting) honored by Emergency Medical Services (EMS) Should indicate with whom discussed as well Concise

7. Features: Recognizable Nevada POLST forms are bright pink Available at: Order at:www.NevadaPolst.orgwww.NevadaPolst.org Download for Educational Purposes: Nevada State EMS: http://health.nv.gov/PDFs/EMS/Forms/POLSTf orm.pdf or, http://health.nv.gov/PDFs/EMS/Forms/POLSTf orm.pdf www.NevadaPolst.org (with watermark: “SAMPLE”) www.NevadaPolst.org

8. Features: Portable POLST Patient EMSFacility ASK

9. POLST Side One: Medical Orders Instructions Patient Information Section A: CPR Section B: Other medical interventions Section C: Physician documentation

10. POLST Side One: Medical Orders Instructions / Patient Information Write the date in the date of birth box: Ex: Feb. 12 1941

11. POLST Side One: Medical Orders Section A: CPR EMS-DNR #: from the salmon colored card No longer necessary; legislature approved POLST to be honored in all settings The salmon colored card is no longer necessary unless someone wants it for use when away from their residence. POLST must be signed and dated by a physician in Section C and the patient or their agent in Section F

12. POLST Side One: Medical Orders Section B: Interventions: Comfort Measures Relevant if: “Allow Natural Death” marked in Section A or Patient is not in cardiopulmonary arrest If checked, patient should remain at current location (home, nursing home, etc.), unless comfort cannot be achieved at this location

13. POLST Side One: Medical Orders Section B: Limited Medical Interventions Remind patient the POLST is ONLY used if they are so sick they can’t speak for themselves. Explain the implications, what it may involve and how it may affect them. Beware of conflicting orders.

14. POLST Side One: Medical Orders Section B: Interventions: Full Treatment Explain the implications. Explain that treatment may or may not be successful, and may result in additional discomfort. Discuss “Additional Instructions” - might include a trial period of treatments to determine tolerance and benefit.

15. P OLST Side One: Medical Orders Section C: Physician Validation REQUIRED for validity Signature Date Other boxes Very helpful should there be any question of validity Printing template at www.nevadapolst.org/nevada-polst- form/printing-instructions/ Printing Repetitive Information for Section Cwww.nevadapolst.org/nevada-polst- form/printing-instructions/ Transfer Reminder

16. 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) Conversation documentation LivingWillLockbox.com information General Instructions

17. POLST Side Two: Patient Preferences Section D: Organ Donation Name and Date of Birth – Verify with patient bracelet Checking Section D box does NOT give authorization for organ donation; check their NV State issued ID to verify

18. POLST Side Two: Patient Preferences Section E: Advance Directive Summary If AD available, complete this section! If AD is registered with the Secretary of State, LivingWillLockbox.com, patient may have an ID card available #2 – State law provides an order of authority for resuscitation orders only.

19. POLST Side Two: Patient Preferences Section F: Signatures Circle the responsible party with whom you have spoken regarding the POLST Agent is the person specified in the patient’s Durable Power of Attorney for Health Care (DPOA) Patient or their representative MUST sign and date it Consent with witness will reduce confusion and conflict when POLST is needed Preparer may be physician (required for Side 1), nurse or social worker

20. POLST Side Two: Patient Preferences Section G: Registry Registry is the Secretary of State’s LivingWillLockbox.com (LWL) Your facility and/or office should: Be registered for access to Livingwilllockbox.com Have a supply of authorization forms on hand Have a process in place to assure POLSTs and ADs are registered Offer both POLST and LWL authorization form at patient interview When signed, or at least explained, initial box

21. POLST Side Two: Patient Preferences Section G Alternative The use of Health Information Exchanges (HIE) assure patient information is available across health care settings and between providers HealthInsight offers HealtHIE Nevada for this purpose. ADs, POLST and other patient medical information can be accessed on HealtHIE Nevada A significant number of providers, labs, pharmacies, etc. have already begun uploading records. For more information: http://www.healthienevada.org/

22. Reimbursement Codes Out-Patient Consultations Wellness codes Fewer than 10% of providers are utilizing wellness codes. Provides an opportunity to review medications, past history and end-of-life considerations In-Patient Consultations CPT II codes NevadaPOLST.org/billing-for-polst-consultation/

23. What are the Legal Implications of POLST POLST is a state approved form (AB344) You 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 a POLST; or, The patient, their agent, parent or legal guardian over- rides it (Any of these may over-ride a POLST form)

24. Physician Authority and Priveleges Health care 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

25. Physician Responsibility A POLST should be completed for a patient if: Their life expectancy is less than 5 years; and, They have a terminal illness or are very frail; or, They request one In these instances, the physician shall explain : The availability of the POLST; The features and procedures offered by it; and, The difference between the POLST and other ADs

26. 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; or, Preferences change When a POLST needs to be revised due to wear/tear or change of orders or other information Write VOID diagonally across both sides of the POLST and place in the patient’s chart Complete a new POLST, sign and date it

27. Conflicting Documents Should an AD and POLST conflict, the most recent one will be considered valid. If a patient has a POLST that directs CPR be given to a patient with a valid DNR identification, CPR shall not be provided if the ID is with the patient regardless of which is more recent. IF A PATIENT HAS A DNR ID THAT CONFLICTS WITH THEIR POLST, determine which treatment they wish, then complete a POLST reflecting those orders. Ask the patient to destroy their DNR card to avoid confusion.

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

29. Blank Sections and Other States’ POLSTs Any completed section is valid unless the POLST is not signed and dated by a physician (Section C) and the patient or the patient’s representative (Section F). Blank sections should be presumed to indicate full treatment, unless it conflicts with a completed section. A valid POLST (MOST, POST, MOLST) of another state shall be honored in Nevada.

30. Journal of the American Geriatric Association (JAG) Association Between Physician Orders for Life- Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon Published Online June 9, 2014 – Available soon in June issue of JAG 17,902 subjects – largest study to date RESEARCH

31. RESEARCH – POLST Preferences and Hospital Deaths POLST Preferences Comfort Measures Only – 66.1% Limited Interventions – 26.7% Full Treatment – 6.4% Association between POLST Choices and Hospital Deaths: Comfort Measures Only – 6.4% Limited Interventions – 22.4% Full Treatment – 44.2% For those without a POLST – 34.2% were hospitalized

32. RESEARCH – POLST Preferences and Hospital Deaths Take Away Message Vastly more who complete a POLST choose CMO Those with POLSTs for CMO were significantly LESS likely to die in a hospital Those with orders for full treatment were MORE likely to die in the hospital than those without a POLST This holds for each of the top 10 causes of death. End-of-life preferences to avoid hospitalization as documented in POLST orders are honored

33. Research JAGS, Volume 58 Issue 7, 2010 Stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia, 1711 living & deceased subjects. Residents with POLSTs were more likely to have orders regarding life-sustaining treatment other than CPR ( 98.0% vs 16.1%, P <.001). POLST was more effective than traditional practices at limiting life-sustaining medical interventions residents did not want Residents with POLST forms requesting comfort measures only were less likely to receive medical interventions (e.g., hospitalization), ( P =.004), than residents with traditional DNR orders ( P <.001), or residents with traditional full code orders ( P <.001).

34. Nevada POLST Nevada POLST is a Nevada non-profit formed specifically to: Educate and train the public and health care providers regarding the Nevada POLST Program Provide state approved Nevada POLST forms…bright pink, 65# stock Support other organizations in providing compassionate end-of-life care For more information visit www.nevadapolst.org