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

2. 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

3. 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

4. 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:

5. POLST Paradigm (as of December 2013)

6. Nevada POLST

7. 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 2014.
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.

8. 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.

9. 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

10. 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 does not need to be signed by patient, but the form should indicate who held the discussion with the physician

11. Should be printed on hot pink stock paper (if available)
Nevada POLST Features
Patient
POLST
ASK
ASK
EMS
ASK
Facility
Should be printed on hot pink stock paper (if available)

12. Nevada POLST Features The POLST form is available at many sites:
NVPOLST.com (after March 15, 2014)
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

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

14. Nevada POLST Side One: Medical Orders Instructions & Patient Information

15. 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

16. 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.

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

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

19. Nevada POLST Side One: Medical Orders Section C: Physician Validation
To be valid, the Nevada POLST form must, at a minimum, be signed and dated by a physician.

20. 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

21. 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.

22. 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.

23. 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).

24. Nevada POLST Side Two: Patient Preferences Section F: Signatures
The person who prepares Side 2 circles the responsible party with whom the physician has discussed this document
An agent is the patient’ Durable Power of Attorney (DPOA) for Healthcare
The patient, agent, parent (if a minor) or guardian signs the POLST form
A witness signature for anyone preparing the form (may be nurse or social worker). Note: A physician must complete side 1 of the POLST form

25. 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

26. 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

27. 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

28. 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

29. 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

30. Nevada POLST Law: 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, unless it is dated prior to the POLST

31. 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

32. 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

33. POLST @ 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)

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