1. Physician Orders for Life Sustaining Treatment (POLST):
Past, Present and Future

2. Supporting National Healthcare Decisions Day, April 16
POLST: Past, Present and Future Answering Your Questions About Illinois’ POLST Program
April 9, 2014
Supporting National Healthcare Decisions Day, April 16
Julie Goldstein, MD polstil.org

3. Conflict of Interest
Dr. Goldstein is receiving no monetary reimbursement for this presentation.
Apart from her role as chair of the POLST Illinois Taskforce, Dr. Goldstein is also certified State Faculty for the Respecting Choices® Physician Orders for Life-Sustaining Treatment Paradigm Program.
Respecting Choices® is one of many programs available for POLST training and is not specifically endorsed by the POLST Illinois Taskforce.

4. Disclaimer
The legislation that covers the use of the IDPH Uniform DNR Advance Directive/POLST form in Illinois does not provide guidance in all areas.
The views expressed during this webinar represent the POLST Illinois Taskforce’s current assessment based on available information.
Dr. Goldstein is not providing legal or medical advice. Please consult your institution’s legal counsel when appropriate.

5. Agenda
Brief overview and history of POLST – for more detailed information visit
Participant polls conducted throughout the webinar to help us gauge level of use and understanding
Review commonly asked questions (top 20 with answers are posted on website)
Participant questions
Follow up slides incorporating additional questions from the call will be made available
If you have any questions, please ask during the webinar by using the function on the right
If we are unable to get to all of the questions asked during the webinar, we will follow up with you.
For more detailed information including presentations and training materials, please visit the POLST website 4

6. Background
In March, 2013 Illinois modified the “IDPH Uniform DNR Advance Directive” to bring it closer to the National POLST paradigm standards used in other states.
In this presentation, “POLST” is being used to refer to the form as shorthand.
POLST stands for “Physician Orders for Life-Sustaining Treatment”. 5

7. POLST Use in the United States
Oregon released the first POLST form in 1995
Gradually expanded throughout the U.S.
15 states with endorsed/mature programs
27 states developing programs (including IL)
The national POLST Paradigm Initiative Task Force aids state programs with patient safety, quality improvement, and educational resources
Mature Program
Endorsed Program
Developing Program
No Program

8. Benefits of IDPH DNR/POLST in Illinois
Promotes patient-centered quality care
Concrete medical orders that must be followed by healthcare providers
Follows patient from care setting to care setting
Reduces medical errors by improving guidance during life-threatening emergencies 7

9. POLST is NOT for everyone!
The POLST program is designed for:
Patients facing life-threatening complications, regardless of age; and/or
Patients with advanced frailty and limited life expectancy; and/or
Patients who may lose the capacity to make their own health care decisions in the next year (such as persons with dementia); and/or
Persons with strong preferences about current or anticipated end-of-life care.
It has been suggested by some that a POLST form not used for a person wanting CPR, since that is the default approach if no form exists.
Surprise question: “Would you be surprised if this patient died within the next year?”

10. Advance Care Planning IS for Everyone!
ACP Life Cycle
First Phase:
Complete a PoA. Think about wishes if faced with catastrophic neurological injury.
Next Phase:
Consider if, or how, goals of care would change if interventions resulted in bad outcomes or severe complications.
Last Phase:
End-of-Life planning - establish a specific plan of care using POLST to guide emergency medical orders based on goals.
Healthy and Independent
Advancing Chronic Illnesses and Functional Decline
Multiple Co-Morbidities and Increasing Frailty
The segmented bar in the middle represents the 3 “phases” of the Advance Care Planning “Life Cycle.” There is much information here, and most likely it will need to be briefly summarized in order to get through the entire presentation.
The First Phase begins at adulthood. Anyone 18+ should be encouraged to start advance care planning as a healthy life habit. For a Healthy and independent adult, there are only a few advance care planning “tasks”. The first is to consider “Who in my life would I trust to represent my medical wishes if I couldn’t speak for myself?”. The second is to put that choice in writing in the form of a power of attorney for healthcare document. The third is to consider “If I suddenly became irreversibly neurologically devastated, ie., vegetative, would I want ongoing treatment or would I want to be allowed to die?” (be aware that this is a controversial subject for observant Catholics). The fourth is to notify the selected agent, and give that person a copy of the document. These are the “First Steps”.
The Next Phase begins when a patient has a chronic illness that has begun to advance such that there is a functional decline. For this patient, the life habit continues, and is built upon the considerations in the First Phase. Now it is time to think about one’s specific conditions and the specific kinds of deterioration that can be can be expected with those conditions. For example, a person who has COPD is now requiring oxygen use at home, and/or is experiencing hospital admissions for acute exacerbations. That patient should understand the risk of being intubated and the nature of that procedure including its benefits and burdens. The patient should also consider whether, if unweanable, tracheostomy and longer-term care in a facility that treats patients on ventilators would be acceptable, and if so, would there come a point when it would no longer be acceptable? If there are no limitations of treatment desired at this point, there is not a new document to complete here, but specific discussion about specific treatment wishes is appropriate, with both the primary care provider as well as the identified agent. These are the “Next Steps”.
The Last Phase is when a patient is likely to be in the last year or so of life, as mentioned. This is the patient with multiple comorbities and/or increasing frailty. In this phase, it is possible that the person making decisions is not even the patient, but instead the substitute decision-maker (who is ideally also the assigned agent with Power of Attorney for Health Care). In this phase, there are specific decisions to be made, including wishes about CPR in case of cardiac arrest, and in other critical conditions, level-of-treatment wishes based on patient goals, which can range from strictly comfort care all the way to aggressive treatment with all medically indicated means. These are the “Last Steps”, and are documented on the POLST form so that ALL providers who may encounter this patient in an emergency situation will have guidance regarding the desired treatment(s).
Document on Power of Attorney form
Document on IDPH DNR form

11. Promoting Patient-Centered Care
POLST promotes quality care through informed end-of-life conversations and shared decision-making:
Improve conversations, then translate wishes into actionable medical orders
Encourage quality conversations by skilled persons with proper training (as determined by institution)
A process, not a single conversation
Allows the patient more time to think about future scenarios and discuss them with family, friends and care providers 10

12. POLL: Is Your Organization Completing POLST forms with Patients?
Use webinar buttons on right to provide your answer. Is anyone having any problems with polling feature?
Answers:
Frequently
Occasionally
Never 11

13. The IDPH DNR/POLST Form in Illinois
The POLST form is available on the IDPH website and at – in English and Spanish. It is recommended that the form be completed in English, even for Spanish speaking individuals to ensure EMS interprets the form correctly. The Spanish version of the form can be helpful for education.
It is recommended that the form be bright pink so it can be easily noticed. Any color of the form is valid. Some nursing homes are using different colors to identify the “old” DNR form and the “new” POLST form.

14. The POLST Form Comfort care for all patients at all times!
3 Primary Medical Order Sections:
CPR for Full Arrest, Yes or No
CPR/DNR applies to persons who have died (unconscious, no heart beat, not breathing)
DNR does not imply the person wishes to limit treatment when still alive
B. Orders for Pre-Arrest Emergency
Treatment for patients who are having emergency deterioration but are not dead
Level of care treatment plans, which can be thought of as “Strictly Comfort Care”, “Limited but Noninvasive Medical Interventions”, or “Full Treatment with all Medically Indicated Treatments”
Artificial Nutrition
Acceptable, Trial or Never 13

15. Proposed Legislation: SB 3076 and HB ?
Proposed Changes:
P in POLST would stand for “Practitioner”; expands who may execute the POLST form to include advanced practice nurses, physician assistants and some medical residents.
Removes “Advance Directive” from title; form complements advance directives as a translational tool, addresses specific medical circumstances with the actionability of a medical order.
Adds “POLST” to “DNR” in formal title; patients may use form to request CPR rather than to request DNR. 14

16. Questions… 15

17. Q: Are we required to follow the orders on the POLST form?
A: YES! Licensed hospitals, EMS and long-term care facilities must honor the IDPH Uniform DNR Advance Directive/POLST document.

18. Following POLST Orders
“A health care professional or health care provider, or an employee of a health care professional or health care provider, who in good faith complies with a do-not-resuscitate order made in accordance with this Act …may not be found to have committed an act of unprofessional conduct.”
- Subsection (d) of Section 65 of the Health Care Surrogate Act, 755 ILCS 40/65
A copy of the form should also be followed. It does not have to be the original.

19. Q:. If the POLST form is considered. a medical order, is it still
Q: If the POLST form is considered a medical order, is it still necessary to get a separate order for a DNR?
A: The instructions on a POLST form must be followed as outlined. It is up to individual institutions to determine if additional formats will be used to communicate DNR orders within the institution.

20. Q:. Is the POLST form active upon. patient signature, or does it
Q: Is the POLST form active upon patient signature, or does it require a physician’s signature?
A: The form is not considered a medical order until the physician has signed it.

21. Q:. Since the order is not valid. until a doctor signs the form,
Q: Since the order is not valid until a doctor signs the form, how do you handle telephone orders?
A: This is based on the policies established within your own institution. If your institution has a policy that allows for telephone orders, then you can accept a POLST order over the phone. The physician should physically sign the form as soon as possible.

22. Q: What should I do with previous IDPH DNR forms?
A: The old DNR form is still valid! Review it with the patient. If a POLST form is more appropriate for the patient after careful conversation with a health care worker, complete a POLST form. The updated IDPH DNR/POLST form is a better form and should be used moving forward.

23. Q: Why isn’t removing “DNR”. being proposed in the
Q: Why isn’t removing “DNR” being proposed in the legislation for the revised POLST form?
A: In the state of Illinois, we started with a DNR form. The form was then changed to the IDPH Uniform DNR Advance Directive . There are legislative rules and reasons why this term needs to stay in the title for now.

24. Q:. I was under the impression that. the POLST form is only for pre-
Q: I was under the impression that the POLST form is only for pre- hospital, and does not apply for patients in the hospital. Is this true?
A: Yes, the POLST form is meant to serve as instructions for first responders. It also represents the wishes of the patient which are translated into a medical order set. So the instructions that are put into place on the POLST form still apply, unless reconsidered by the patient/substitute decision-maker, even as the patient moves into the hospital and to other healthcare settings.

25. Q: Should all residents in a nursing home have a POLST form?
A: Completing a POLST form is voluntary
Using a POLST form is a practical way to capture both medical orders and patient preferences, but cannot be required
Residents typically meet criteria for using the form
All staff should be trained on the form
Everyone should know what to look for on the form
Some facilities want to use it as a standard form for patient safety
No one can be required to complete a POLST form
Some nursing homes are using different color paper to differentiate a DNR and POLST forms (red and green)

26. POLL: Has anyone in your organization been formally trained on how to have a POLST conversation?
Answers:
Yes, two or more staff have been trained to facilitate a POLST conversation and complete the form
Yes, one staff member has been trained to facilitate a POLST conversation and complete the form No
Please use the tools on the right-hand side of the screen to provide your answer: 20

27. Q: When explaining the POLST form to our residents, they tell us they want to try CPR, but don’t want any machines. How do we respond to that?
A: Part A of the form is an instruction regarding treatment of a patient who has died, who is in “cardiac arrest”, meaning: No heartbeat, No respirations , No consciousness. If a person wants resuscitation attempted when dead, intubation will almost always be a component of this treatment if resuscitation is successful.
In Part B, the intubation that is being described is in the context of respiratory distress or pending respiratory failure, rather than in the context of cardiac arrest.
Most people who express these wishes are not aware that 1) intubation/mechanical ventilation is almost uniformly a short-term outcome of a successful attempt at CPR, and 2) being “on machines” is often not a permanent “condition”. Once this is adequately explained to patients, they generally feel comfortable selecting CPR or no CPR in Part A.

28. Q: What if a patient does not want to complete one of the sections?
A: That’s fine!
Cross out section and write “No Decisions Made”
Doesn’t create false perception of patient wishes
Stops someone else from just checking a box in the future
Treat that section in the same way you would for any patient who arrives without a form
Start a discussion with patient or legal representative

29. Q:. Is Section B of the form required. Some hospices are leaving the
Q: Is Section B of the form required? Some hospices are leaving the section blank. If section B is left blank is the form still valid?
A: If section A is completed, and section B or C are left blank – the POLST form is a valid order in regards to what a first responder should do if the patient has died.
If section B is blank, first responders will treat with all indicated medical treatment.
If the patient does not want to complete sections B and C, rather than leaving it blank, we suggest that a line be drawn through the sections and “no instructions” be written.

30. Q:. If a person does not have a. POAHC, would it be possible to. use
Q: If a person does not have a POAHC, would it be possible to use the Surrogacy Act Priority Order to determine who can sign the POLST?
A: Yes, Illinois law (Illinois Healthcare Surrogate Act) directs us to identify a substitute decision-maker for a patient who lacks decision capacity. We are directed to first look for an agent with POAHC. If there is no agent or POAHC and no other advance directive document that gives adequate instructions for patient wishes, we are then directed to refer to the Illinois Healthcare Surrogate Act hierarchy - starting at the top and moving down.

31. Q:. If a patient has completed a POLST form in
Q: If a patient has completed a POLST form in the hospital and then transfers to a SNF, does the form need to be revised and signed by the attending physician in the SNF? Or can we honor the form from the hospital – given that the patient doesn’t want to make any changes?
A: Any POLST form that has been appropriately completed needs to be recognized in any medical setting.
We have seen situations where a patient is transferred with a POLST form, but a different receiving physician is not aware of the existence of the form. One way to reinforce awareness of the POLST order could be to have the receiving attending physician complete another form (and, in doing so, confirm the discussion and wishes by speaking with the patient and family). In any case, every institution must have a way to communicate to all staff when there is a valid POLST form in place, no matter who has signed the order, so that the patient’s wishes will be honored in an emergency.

32. Q: Is there an official color that should be used for the POLST form?
A: The POLST form is valid on any color paper. A brightly colored form is recommended, and bright pink is the standard color recommended across the country. The bright pink color copies well without creating black smudges.

33. Q:. Should a different color form. be used for the form if a
Q: Should a different color form be used for the form if a person wants to be resuscitated?
A: Some nursing homes are addressing the potential for confusion about whether the form is representing a patient’s wish to have CPR or whether it is representing a patient’s wish not to have CPR by using different colored paper for each. If a patient wants to be DNR the nursing home copies the POLST form onto red paper, and when the patient wants to be full code, green paper.
We are not endorsing this practice, but we think it is a clever way to address this potential for confusion.

34. Q:. Can a nurse sign the physician’s. signature on the form, as he/she
Q: Can a nurse sign the physician’s signature on the form, as he/she would a verbal order, if the physician is not available?
A: Yes, if absolutely necessary. If it is necessary to take a verbal order, the physician should sign the form as soon as possible, according to institutional policy/procedure.

35. Q: Who can sign the POLST form as a witness?
A: The law says anyone over the age of 18
IDPH website adds that witness “may include a family member, friend or health care worker”
Recommend avoiding appearance of conflict of interest
When possible, someone not directly involved in patient’s care, like another nurse, social worker, family member, etc. however this is not required

36. Q:. If the patient is confused, and the
Q: If the patient is confused, and the POA lives out of town, is it acceptable to call the POA and sign it as you would a verbal order from a physician?
A: Ideally, the goal is to complete a POLST form when the patient is still able to make decisions. This is not always possible, however. Whether a clinician can accept a verbal/phone consent from the appropriate decision- maker to a POLST order should be determined by each institution. Institutions can assess whether the practice would be the same for POLST as for other consent forms.
If your pt is confused and the POA lives away and is not available – is it acceptable to call the POA and sign it as you would a verbal order from a physician

37. Q:. I recently received a POLST form in a
Q: I recently received a POLST form in a hospital, and there was information missing including DOB, gender and address. Am I allowed to complete these sections of the current form, or do I need to complete a new form?
A: This something you should check with the policy and procedure person at your hospital.
While I am not a lawyer, I would personally think it would be ok to add those items as long as you are confident you are dealing with the same patient. When a change has been made, initial the addition and maybe write a note in the medical record that you have made the change.
Ultimately, the decision is up to your institution.

38. Q:. Couldn’t the use of red/green. paper increase the risk that the
Q: Couldn’t the use of red/green paper increase the risk that the form won’t be read and that an error in color would lead to the wishes not being followed?
A: You could argue both sides of this point. This practice is determined by policy of individual institutions. Staff and first responder education is critical in any case. The specific orders on the form must be reviewed, rather than making assumptions.

39. Q: Who can authorize the reversal of the POLST orders?
A: The patient, when decisional, or the appropriate substitute decision-maker/legal representative can revoke previous POLST orders.
Physicians and other practitioners may not reverse the POLST orders unless authorized by the appropriate decision-maker.

40. Reversal of POLST Orders
Extreme care should be taken when a substitute decision-maker wishes to reverse the direction of care previously established by the patient, particularly if the patient had selected a treatment plan that focused on comfort care.
A legal representative may make new decisions, but generally should not be permitted to overturn decisions already made by the patient ,unless there is evidence that the patient had faulty information, misunderstood the information given, or would have changed decisions based on current developments in his or her medical condition.

41. POLL: How confident are you that staff in your facility are able to interpret a patient’s completed POLST form inthe setting of a medical emergency?
Answers:
Completely
Somewhat
Slightly
Not at all
Does not apply 27

42. Q:. Should organizations use stickers on a
Q: Should organizations use stickers on a patient’s chart to indicate POLST orders?
A: A time-honored practice has been to signal critical patient information (e.g., allergies, code status, etc.) by placing stickers on the fronts of paper charts.
The more information included on a sticker, the more chance there is for human error in transferring information from the form. The POLST form is complex, and is used to reflect patient wishes following a detailed conversation. There is a risk of information being lost when “shorthand summaries” could replace review of the actual form, especially in an emergency.
Each institution should assess their own level of staff understanding/education to determine policy/procedure regarding this issue.
Having a sticker that simply cues staff that a patient has a POLST and to look for it could be risky. Staff could assume that POLST means the patient has selected DNR, and thus withhold CPR from a patient who wanted resuscitation attempted in case of cardiac arrest.

43. Q:. In a skilled nursing facility,. should the POLST form be
Q: In a skilled nursing facility, should the POLST form be signed by each resident’s PCP or our medical director?
A: This is my personal opinion, but I believe it depends on who would be contacted in the case of an emergency. If the practice is to call the patient’s primary care physician when there is a medical deterioration, it would make sense that this physician is the one involved in the conversations who then signs the form.
It is critical that there is communication with any treating physician about the existence of the form for a patient who is deteriorating, to ensure the instructions on the form are followed. The physician communicating with the first responder needs to be aware of the instructions.

44. For Updates and Current Information
For more information on the National POLST program, visit
For Illinois-specific resources, visit
Illinois POLST will be setting up Facebook and Twitter accounts in the near future.

45. Thank You
Dr. Julie Goldstein
polstil.org 31

46. Telligen’s Contact Info
Meghan Foley
Project Assistant