0. A Review Advance Directives and POLST 6/30/14

1. Objective To Review Highlights of Advance Directives and POLST
Describe rationale for and use of each document
Discuss differences between advance directives and POLST
Define who can be a Pennsylvania Health Care Decision-Maker
This presentation will review the topics of advance directives and POLST which were described in detail in the pre-course.
We will discuss what advance directives are and how/when they are used. At the outcome, it is expected that the difference in the two documents will be clear.
We will also talk about who can be the health care decision-maker for another.
One reason for this, is that we want to be sure that it is the legal medical decision-maker that would be making treatment decisions for another person.

2. Key Points
What are the differences between advance directives and POLST
What are the differences in the powers of a health care agent and a representative
POLST does not replace an advance directive
If the choice in Section A of the POLST is for CPR, the choice is Section B, Medical Interventions, needs to be Full Treatment
There are some other Key Points that will be upcoming in the discussion and they are noted on this slide.
These points are:
Differences between advance directives and POLST
There are differences in the powers of a health care agent and a representative
POLST does not replace an advance directive
If the choice in Section A of the POLST is for CPR, the choice is Section B, Medical Interventions, needs to be Full Treatment
A reason to focus is that these concepts are often misunderstood by health care professionals. They are also concepts that you will want to make sure are understood by you and those for whom you will be providing training.

3. Advance Directives A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.
The goal of an advance directive is to patients to retain control over the life-prolonging treatment they receive.

4. Advance Directive Recommendation
Anyone may face a sudden and unexpected acute illness or injury with the risk of becoming incapacitated and unable to make medical decisions
Everyone age 18 and older should be encouraged to complete a Health Care Power of Attorney document and to engage in advance care planning discussions with family and loved ones
An ongoing conversation over the years with your healthcare decision-maker, family, and healthcare provider is very important
Why is an advance directive important?
Anyone may face a sudden and unexpected acute illness or injury with the risk of becoming incapacitated and unable to make medical decisions.
Everyone age 18 and older should be encouraged to complete a Health Care Power of Attorney document and to engage in advance care planning discussions with family and loved ones.
An ongoing conversation over the years with your healthcare decision-maker, family, and healthcare provider is very important.

5. Advance Directives
PA Act 169 provides for health care decisions to be made for an adult patient through three means:
A living will (LW)
A health care agent appointed by the patient (HCPOA)
A close family member or another to serve as a health care representative for the patient
Usually LW and HCPOA are combined in single document
Individuals can guide their own health care treatment through the completion of a living will and by naming a health care agent.
While a living will and health care power of attorney are generally found in a combined document, both do not necessarily need to be completed. What is important for many, especially for persons who are in a healthy state, such as a young person, is to identify some one who can make another’s health care decisions if they become unable to do so for them self.
If an agent is not named, the law provides for a representative to be designated. However, a representative may not have a clear understanding of the person’s values and treatment choices.

6. Advance Directives Who can make a directive? Adult Sound mind
18 years of age or older
Graduated from high school
Married, or
Emancipated
Sound mind
Any person can make an advance health care directive if they are 18 years of age or older or legally considered an adult, and of sound mind.
Advance directives are not only for the older person and those who are ill. Everyone in this room should consider completing their own directive and to encourage family members to do so.

7. Living Wills
A written statement of the patient’s personal choices regarding life-sustaining treatment and other end of life care
Becomes effective when a patient is incompetent and has an end stage medical condition or is permanently unconscious
Note when a living will becomes effective. It is when a patient:
Is incompetent
and
has an end stage medical condition or
Is permanently unconscious.
An example when a living will is not effective is when someone who has specified they do not want CPR if in an end stage medical condition, is admitted to a hospital with a non-end stage medical condition.
It does not mean they want to be defined as DNR during that hospital admission.

8. Health Care Power of Attorney
A written document in which a person appoints another to serve as his agent and to make health care decisions
States when and what decisions an agent may make
States patient’s preferences and values to guide decision-making
It is important to choose someone who will be able to make the difficult decisions. Someone who
Knows your wishes and values
Understands how you would make decisions if you were able
Is not afraid to ask questions and advocate to doctors

9. Advance Directive Examples
This slide shows you examples of two widely used advance directive documents.
The document on the left was developed through the cooperation of the Allegheny County Bar Association and the Allegheny County Medical Society is consistent with Pennsylvania’s Advance Directive Law and can be used anywhere in the state. It is the only living will and health care power of attorney form officially endorsed by both doctors and lawyers in Pennsylvania. This form is available online at no cost.
The Five Wishes form meets the legal requirements in 42 states including PA. It has become America’s most popular living advance directive document and can be purchased at the website shown on the slide.

10. Online Example – Useful Tool for Public
This is a tool that can guide a person through the process of medical decision making. In addition to viewing slides, the user can listen to instructions.
One of the most unique features of the PREPARE site is the ease of navigation. This user-friendly site implements videos and step-by-step instructions to help even computer novices gather information and develop an action plan for elderly care.
Slides walk you through the process and the user can listen to instructions. 10

11. Above slide shows the five different areas that are covered.
There are several major topics that are addressed on the PREPARE site, including:
Choosing a medical decision maker
Deciding what matters most in life
Choosing flexibility for you decision maker
Telling others what you want
Asking doctors what you want.
Above slide shows the five different areas that are covered.
It all does not need to be done at one time.

12. Advance Directive Triggering Event
Patient is in a state of:
Incompetency
End stage medical condition
Permanently unconscious
*In the Pennsylvania statute, “incompetency” is the term that is used. In practice, the term in often used interchangeably with “lacking capacity”.
What is Competency in Health Care Decision-Making? What does it mean to have capacity for decision-making?
A competent patient not lacking capacity:
Understands potential benefits, risks, and alternatives of the decision
Is able to make the decision
Can communicate the decision
If unable to perform any of above, the patient is incompetent and lacking capacity
What is an end state medical condition?
An incurable and irreversible medical condition in an advanced state that will result in death, despite the provision of medical treatment.
There is no maximum life-expectancy in definition.
What is Permanent Unconscious:
Total and irreversible loss of consciousness and capacity for interaction with the environment
• Irreversible vegetative state or irreversible coma

13. Capacity Assessment of Capacity Elements of capacity
Not always constant or fixed
Not always absolute either/or
Capable for some decisions/not all
Elements of capacity
Ability to understand situation and that there is a decision to be made
Able to communicate preference
Able to make a judgment/choice
Able to give rational reason for choice
Capacity may vary. Capacity may need to be evaluated at different times and in different circumstances.
For example, someone may not be able to make decisions in an ICU unit, but may be able to do so at a later time.
A patient may not have capacity for finances but still may be able to have capacity to make medical decisions.
NOTE REGARDING USE OF TERMS INCOMPETENT/ LACKING CAPACITY/INCAPACITATED: In the Pennsylvania statute, “incompetency” is the term that is used. In practice, the term in often used interchangeably with “lacking capacity” or incapacitated”.

14. Decision-makers Health care agents
Designated in a health care power of attorney
Authority is usually limited to when patient is incompetent/not lacking capacity
Not restricted to end-of-life decision-making
Patients usually give health care agents the power to make their health care decisions only when they are incompetent.
However, in contrast to living wills, patients may elect to give their agents the power to make their health care decisions even when they are competent.
Another important contrast with living wills is that the law does not restrict health care agents to end-of-life decision-making.
For example, an agent could have the power to make health care decisions for an unconscious patient injured in an automobile accident even though the patient’s condition is not end-stage.

15. Decision-makers
Health care representatives may make health care decisions for an incompetent patient/lacking capacity who has:
No health care agent (or no reasonably available agent)
No legal guardian of the person
Unfortunately, there will be many occasions when an adult patient is incompetent (lacking capacity) to make a health care decision, but the patient has:
No applicable living will that clearly provides instructions for the decision,
No health care agent at all, or no health care agent who is reasonably available to make the decision, and
No legal guardian of the person who is authorized to make the decision.
Act 169 provides for a health care representative to make the decision for the patient in these situations.
However, Act 169 does not take into account the non traditional family or unmarried couples so for all those people a health care power of attorney is particularly important if they want to assure the person of their choice is the one recognized as their legal decision-maker.

16. Decision-makers Health care representatives
May be designated by patient. For example, during the admission process, an adult patient may designate his representative should he become incompetent during his hospital stay
If not designated, selected from priority list in law
A patient of sound mind may designate someone as his health care representative.
To designate a health care representative, a patient need only name the person as his representative in a signed writing or personally communicate this to the health care provider.
For example, during the admission process, an adult patient may designate his representative should he become incompetent during his hospital stay.

17. Decision-makers
If no agent appointed, the law gives priority in this order:
Current spouse and adult child of another relationship
Adult child
Parent
Adult sibling
Adult grandchild
Close friend
The new law generally gives priority to the following classes in this order:
spouse and child of a prior relationship,
adult child,
parent,
adult sibling,
adult grandchild,
close friend.
Under the PA statute, since a spouse and child of a prior relationship have equal weight, this is an example that speaks to the importance of naming an agent. 
Again, the statute does not take into account the non traditional family or unmarried couples so for all those people a health care power of attorney is important.

18. The document shown is one of the course resources
The document shown is one of the course resources. It defines the various power of health care decisions makers.
For example:
who can sign a POLST or Living Will,
who can revoke such documents.
We will look at some examples on the following slides.
NOTE REGARDING USE OF TERMS INCOMPETENT/ LACKING CAPACITY/INCAPACITATED: In the Pennsylvania statute, “incompetency” is the term that is used. In practice, the term in often used interchangeably with “lacking capacity” or incapacitated”.
This is page one of a document that defines the various power of health care decisions makers. Full document found at POLST website,

19. Who is the Pennsylvania Decision-Maker
Quick Start Guide Health Care Decision-Making*
If the patient is unable to engage in the POLST discussion, it is critical that the conversation occurs with the correct legal decision-maker
Power to Sign POLST or Agree to DNR
Competent Patient - Yes
Health Care Agent - Yes
Guardian - Yes, but..
Health Care Representative - Yes, but…
Incompetent Patient – No
*Copyright 2012 Robert B. Wolf, Esquire
This slide and the next two outline some of the detail from the Quick Start Guide:
Can a guardian or a health care representative sign a POLST or agree to DNR
Guardian - Yes, but..
Health Care Representative - Yes, but…
Guardians and Health Care Representatives may decline health care necessary to preserve life only if end stage medical condition or permanent unconsciousness
So if someone has a condition for which they are expected to survive, such as a head trauma, legally a guardian or HC representative cannot decline care to preserve life.
This slide defines a difference in the powers of a agent and a representative/guardian. An agent is able to sign a POLST and/or agree to a DNR
This is one of the take-away points from this presentation.
NOTE REGARDING USE OF TERMS INCOMPETENT/ LACKING CAPACITY/INCAPACITATED: In the Pennsylvania statute, “incompetency” is the term that is used. In practice, the term in often used interchangeably with “lacking capacity” or incapacitated”.

20. Who is the Pennsylvania Decision-Maker
Quick Start Guide Health Care Decision-Making*
Power to Revoke a POLST or DNR Order
Competent Patient – Yes
Health Care Agent - Yes if signed by Agent - Otherwise maybe
Guardian - Yes, if signed by Guardian
Health Care Representative -Yes, if signed by Health Care Representative
*Copyright 2012 Robert B. Wolf, Esquire
How about the power to revoke a POLST or DNR order?
A competent patient? Sure.
A healthcare agent would have the power if the order were signed by the agent. If signed by the patient prior to incompetency it is a tougher question. You need to examine the power of attorney very carefully.
A guardian of the person or a health care representative would have the power to revoke if they signed the POLST or agreed to the order.
If it were the patient’s decision while competent, it is a tougher question. Any clear instruction of the patient while competent has substantial weight.
This can get complicated and confusing, especially if the patient’s competency is unclear—keep the Quick Start Guide Handy.
NOTE REGARDING USE OF TERMS INCOMPETENT/ LACKING CAPACITY/INCAPACITATED: In the Pennsylvania statute, “incompetency” is the term that is used. In practice, the term in often used interchangeably with “lacking capacity” or incapacitated”.

21. Who is the Pennsylvania Decision-Maker
Quick Start Guide Health Care Decision-Making*
Power to Decline Care Needed to Preserve Life
Competent Patient – Yes
Health Care Agent – Yes
Guardian – Yes, if End State Medical Condition (ESMC) or Permanently Unconscious (PU)
Health Care Representative - Yes, if ESMC or PU
Incompetent Patient - No
*Copyright 2012 Robert B. Wolf, Esquire
What about the fundamental question—do they have the power to decline care needed to preserve life?
A competent patient – of course
A health care agent– absolutely if properly empowered
A guardian or a health care representative may only decline care needed to preserve life if a patient is in an end state medical condition or permanently unconscious.
An incompetent patient has no such power.
NOTE REGARDING USE OF TERMS INCOMPETENT/ LACKING CAPACITY/INCAPACITATED: In the Pennsylvania statute, “incompetency” is the term that is used. In practice, the term in often used interchangeably with “lacking capacity” or incapacitated”.

22. POLST POLST is designed to honor the freedom of persons with advanced illness or frailty to have or to limit treatment across settings of care.

23. What is POLST POLST is a voluntary process that:
Translates a patient’s goals for care at the end of life into medical orders that follow the patient across care settings
Consists of medical orders that are based on a patient's medical condition and his/her treatment choices as established in communication between the patient or the legal medical decision-maker and a health care professional
Allows health care providers to know a patient’s wishes in the event of a serious illness and to honor them
In some institutions, the POLST document is used to establish goals of care for all patients
A POLST translates a patient’s goals for care at the end of life into medical orders. These orders follow a patient as they transition from one care setting to another, from acute to long term care to hospice care and back.
Consists of medical orders that are based on a patient's medical condition and his/her treatment choices as established in communication between the patient or the legal medical decision-maker and a health care professional. A POLST is not be completed without a conversation on goals of care.
POLST is designed to improve the quality of care people receive at the end of life by turning patient goals and preferences for care into medical orders.
This is a significant difference from an advance directive document.
Note: In some care settings, POLST forms may be offered to all individuals to establish and document goals of care. This could include residents for whom you would be surprised if they died within a year. This is because it a requirement to document CPR status and facilities prefer to use one consistent form as using different forms could lead to confusion.

24. POLST and Advance Directives
The POLST is not intended to replace an advance health care directive document or other medical orders
The POLST process and health care decision-making works best when a person has appointed a health care agent to speak for them if they become unable to speak for themselves
A health care agent can only be appointed through a health care power of attorney
The POLST is not intended to replace an advance health care directive document or other medical orders. Everyone over 18 should have an advance directive. The POLST is recommended for only small percent of individuals.
The POLST process and health care decision-making works best when a person has appointed a health care agent to speak for them if they become unable to speak for themselves.
Ideally, if a POLST is appropriate and the patient is incompetent/incapacitated, an appointed health care agent who understands the values and choices of the patient is the best person to be engaged in the POLST conversation.

25. Who Would Benefit from a POLST
There are no age specifications. Anyone with
Advanced illness
A serious health condition
Medical frailty
Advanced age and wishing to further define their preferences for care
Tool for determination
Ask yourself “would I be surprised if this patient died within the next year”.
POLST can be used for individuals of all ages, both for pediatric and adult populations.

26. POLST Form Highlights
Physician, physician assistant or CRNP medical order
Standardized form, bright distinct color
Based on conversation for goals of care
May be used to limit medical interventions or clarify a request for all medically indicated treatments including resuscitation
Transferrable across care settings
The form is to be signed by Physician, physician assistant or CRNP. It then becomes a medical order.
The standardized POLST form is recognized by its bright distinct color. In PA, it is bright pulsar pint. In other states the form may be another shade of pink, green, lime, yellow.
The most important element is that the form is to be based on conversation for goals of care. The goal is not to complete the form, the goal is to have the conversation.
The POLST is not just for those who want to limit care. While the POLST may be used to limit medical interventions for some patients, it can also clarify a request for all medically indicated treatments including resuscitation in others.
An advantage of the form is that it is transferrable across care settings so patients’ choices for care are carried with them across care settings When health care professionals are transferring a patient, they need to make sure the POLST form goes with them.

27. POLST, Who Fills it Out?
Physician or physician designee facilitator (RN, NP, PA, Social Worker)
Facilitators need to be skilled, knowledgeable and credible to physicians/providers as well as patients and families
Verbal orders are acceptable with follow-up signature in Pennsylvania in accordance with facility/community policy
There are disciplines other than physician, physician assistant or CRNP who may facilitate the POLST conversation. Typically this would be a nurse or social worker.
Regardless of who meets with the patient and/or medical decision-maker, an effective conversation must occur. This requires that facilitators be skilled, knowledgeable and credible to physicians/providers as well as patients and families.
The POLST form can be completed as a verbal order, as any other verbal medical order. Institutions would want to make sure this is addresses in a facility policy.

28. Requirements to Make the Form Valid
Patient name (date of birth recommended)
Completion of Section A, resuscitation orders
Physician/PA/CRNP signature*
Patient or surrogate signature
All other information is optional
One a patients preferences are made known, the POLST form can be completed. To be sure it is valid, include the
Patient name and the date of birth is recommended
Section A must be completed.
It becomes a medical order when the signature of a doctor, PA or CRNP is obtained. If signed by a PA, a doctor must sign within 10 days.
*In Pennsylvania, a physician assistant signature requires a physician
co-signature within ten days.

29. Differences between POLST and Advance Directive
Characteristics
POLST
Advance Directive
Population
For the seriously ill
All adults
Timeframe
Current care
Future care
Who completes the form
Health Care Professionals
Patients
Resulting form
Medical Orders (POLST)
Advance Directives
Health Care Agent or Surrogate role
Can engage in discussion if patient lacks capacity
Cannot complete
Portability
Provider responsibility
Patient/family responsibility
Periodic review
This slide defines differences between a POLST and an advance directive.
POLST is not for everyone, but everyone over 18 should have an advance directive.
The POLST clarifies how a patient wants to be medically treated now.
The POLST can be completed on behalf of the patient by a medical decision-maker if the patient lacks capacity. No one else can complete a patient’s advance directive.
Once a POLST has been completed health care professionals need to assure that is goes with the patient from one care setting to another. Patients/family members are responsible for taking an AD from one site to another.
It is the responsibility of the health care provider to periodically review the form. An individual would review his own AD.
Above table based on:
Sabatino, Charles; Karp, Naomi, AARP Public Policy Institute, (2011) “Improving Advance Illness Care: The Evolution of State POLST Programs”, p4.

30. Advance Care Planning Continuum
Where Does POLST Fit In?
Advance Care Planning Continuum
Age 18
Complete an Advance Directive C O N V E R S A T I
Update Advance Directive Periodically
Diagnosed with Advanced Illness or a Serious Health Condition (at any age) or Medical Frailty*
What is the word along the left side? Conversation.
As choices for care can change, ideally over the years, individuals will have an ongoing conversation with their healthcare decision-maker, family, and healthcare provider.
What is a choice for someone at 18 may not be their choice at 50 or 75 years of age or later.
Also, the person chosen to be the health care decision-maker may change.
Complete a POLST Form
Treatment Wishes Honored
*Someone for whom you would not be surprised if they died within a year
Materials adapted and used with permission from the Coalition for Compassionate Care of California,

31. Pennsylvania Form
HIPAA Compliant
Clear instruction on when to transfer to hospital and use of intensive care
Cardiopulmonary clarifies type of resuscitation. Do Not Attempt Resuscitation assists clinicians in communicating odds about success
IV fluids in Limited Additional Interventions section
Options give people the choice to decide later since issue of when to use antibiotics is complex
Artificial hydration and artificial nutrition both found here
This is a view of the POLST form and its various sections. We will just quickly review the form now and will be looking at the various sections later in this course.
Section A is where someone choice for CPR or DNR is indicated. This applies to a patient when he is not longer breathing and has no pulse. We will talk about the benefits and burdens of CPR in a moment.
Section B is where we distinguish between various medical interventions for a patient who has a pulse and/or is breathing. This is especially useful in a nursing home as it will describe how a resident wants to be treated now.
Choices can range from full treatment that can include mechanical ventilation and cardioversion.
Limited additional interventions would not include intubation and ventilation. Patients who choose this may or may not want other types of therapy, including chemo and radiation.
Comfort measures focuses care on maximizing comfort through symptom management. It could mean a transfer to a hospital if comfort could not be provided in the current locations.
Other choices on the form are for antibiotics and hydration and nutrition.
If any section left unmarked, the highest level of treatment must be provided
Discussion about treatment preferences is required

32. Section A Cardiopulmonary Resuscitation
In choosing CPR or DNR, patients need understanding of the benefits/burdens
Television portrayal of CPR unrealistic with 66% surviving. In real life for elderly patients
22% may survive initial resuscitation
10-17% may survive to discharge, most with impaired function
Chronic illness, more than age, determines prognosis in the elderly
With chronic illness, average survival rate less than 5%.
With advanced illness, survival rates are often less than 1%
Annals Int Med 1989; 111: ;
NEJM.1996; 334(24):
JAMA 1990; 264:
FAST FACTS AND CONCEPTS # 024 and #179
When making a choice in Section A about CPR or DNR, often clarification needs to be made and patients don’t really understand the benefits and burdens.
From watching television, many people believe the rate of CPR survival is much greater than it is. In real life, only about 22% may survive initial resuscitation and 10-17% may survive to discharge. Most of the time people are left with impaired function.
For patients with chronic illness, the survival rate is less than 5% and with advanced illness, few survive. This would be less than 1%.

33. Section A CPR and Medical Interventions
If choosing “Attempt Resuscitation / CPR” in Section A, “Full Treatment” is required for Section B, Medical Interventions
It is not appropriate to request “Attempt CPR” and “Comfort Measures Only”
If a person wants CPR, they must be willing to have ACLS (Advanced Cardiac Life Support) guidelines followed, which usually includes intubation and care in the ICU
It is important for those who are facilitating a POLST discussion to know that for those who want “Attempt Resuscitation / CPR” in Section A, “Full Treatment” is required for Section B, Medical Interventions.
This is because a CPR attempt usually involves intubation and transfer to ICU followed by aggressive care.
It is also important to educate patients/families so they have this information when making a decision.

34. Section A DNR and Medical Interventions
“Do Not Attempt Resuscitation / DNR” may be chosen with any of the medical interventions in Section B
“DNR” with “Full Treatment”
Can choose to receive aggressive medical interventions, but doesn’t want to be resuscitated if found without a pulse or not breathing (they have died)
Those who choose “Do Not Attempt Resuscitation / DNR” may choose any of the medical interventions in Section B, comfort measures, limited or full treatment.
Patients may want full treatment but still want DNR. This is a choice for aggressive medical treatment including ventilation and ICU. However, these patients to not want resuscitation initiated if found without a pulse and not breathing and natural death has occurred.

35. Diagram of POLST Medical Interventions
CPR
DNR
Comfort Measures
Limited Interventions
This above diagram demonstrates the medical interventions choice for someone that wants CPR and for those who do not want resuscitation.
This slide and the choices for Medical Interventions will be covered in detail in Module 3.
Next, I want to direct you to the top of the POLST form.
Full Treatment*
*Consider time/prognosis factors under “Full Treatment”
“Defined trial period. Do not keep on prolonged life support.”
Materials adapted and used with permission from the Coalition for Compassionate Care of California, 35

36. POLST and EMS At top of form it states:
To follow these orders, an EMS provider must have an order from his/her medical command physician.
This is a unique requirement in the PA form and it is because of the Out-of-Hospital Non-resuscitation Act that applies to EMS responders.

37. Orders from a medical command physician
Out-of-Hospital DNR
EMS providers may only follow a PA OOH-DNR order, bracelet, or necklace. or
Orders from a medical command physician
In our state EMS providers may only follow a PA OOH-DNR order, bracelet, or necklace.
An out-of-hospital DNR order is a written order that is issued by a person’s attending physician that directs EMS providers to withhold CPR from the person in the event of that person’s cardiac or respiratory arrest.
If an ambulance is called to attend to a person for whom an out-of-hospital DNR order has been issued and the ambulance crew observes the out-of-hospital DNR order with original signatures with the person, or observes that the person is wearing an out-of-hospital DNR bracelet or necklace, the ambulance crew will not attempt CPR.

38. The standardized POLST allows for faster and more efficient discussion between EMS and the medical command physician.
When presented the PA POLST, the form should simplify any discussion related to termination of resuscitation efforts with a medical command physician.
Customarily, when a medical command physician is informed of the POLST orders, instruction will be give to honor the POLST.

39. Pennsylvania Form 2nd Side
This side includes:
Surrogate Contact Information
A line for the signature of a POLST Facilitator who completes the form
This slide views the back of the form.
Course attendees needs to read the directions for completing, using, reviewing and revoking the form.
Currently, the POLST form is not available on the Pennsylvania Department of Health website. It is found at:

40. Revocation of POLST Form
May be revoked by patient at any time
If patient lacks decision-making capacity, a legal decision-maker may revoke
Revocation can be a verbal statement
Draw a line through sections A through E of the invalid POLST
A comment could be made in the medical record on reason for revocation or change.

41. Transfer Health care institutions Original pink form
Transferred with individual (Use of original form is highly encouraged)
Photocopies and Faxes of signed POLST forms are valid
It is recommended that copies be made on pulsar pink paper
Health care institutions
Keep duplicate copy in permanent medical record upon discharge
Also make copy prior to inter-facility transports

42. Key Take Away Points
What are the differences between advance directives and POLST
What are the differences in the powers of a health care agent and a representative
POLST does not replace an advance directive
If the choice in Section A of the POLST is for CPR, the choice is Section B, Medical Interventions, needs to be Full Treatment
We have covered lot in this session. Among the detail, key points are shown on this slide. This are among the most important concepts to communication in training sessions you conduct.
Are there any questions about this or anything that we have covered?

43. Acknowledgment
We would like to recognize the Pennsylvania Medical Society for use of materials from: “A Guide to Act 169 for Physicians and Other Providers”