1. NORTH AMERICAN HEALTHCARE PHYSICIAN ORDERS FOR LIFE SUSTAINING TREATMENT (POLST)

2. POLICY Facility will advise residents about their rights to make health care decisions and prepare advance directives POLST takes the previously expressed wishes of an individual and translates them into a set of physician orders for medical treatment

3. POLICY POLST is a form recognized as a way to communicate physician and nurse practitioner’s orders based on an individual’s wishes for life-sustaining treatments across healthcare settings. POLST to be reviewed periodically  State and county laws may differ in their support for POLST

4. POLICY The physician will sign the POLST form when it is used at the facility in order for the POLST to be valid. POLST is valid when signed by resident, legal representative or surrogate decision maker and physician.

5. GUIDELINES POLST allows the individual to transfer their wishes from any care setting.  Uniform document addresses decisions related to resuscitation, tube feedings, antibiotics, etc.  Communication with resident or their surrogate decision makers must be documented in the resident’s medical record.

6. GUIDELINES POLST does not replace the Advance Directive!  Dual forms are not necessary Does take the place of the Preferred Intensity of Care (PIC) form.

7. GUIDELINES Resident arriving with a complete POLST, it will be honored during the initial comprehensive assessment period  No longer than 14 days  It should be reviewed with resident/responsible party to assess for any changes If no changes, the POLST form will be placed in the medical record.

8. GUIDELINES POLST form will be added to the record inventory list. POLST instructions will be added to the physician orders. The resident/legal surrogate decision maker can revoke treatment decisions on the POLST at any time.

9. ASSESSMENT & REVIEW Residents arriving  File the POLST  Assure staffs know there is a POLST  POLST will be honored Initial comprehensive assessment period (no longer than 14 days) Note: Best to enter on admission the due date on [ ] Care Plan [ ] physician’s orders with “DC” date and then renew order  Review with the resident and/or legal surrogate decision maker in assessment period.

10. ASSESSMENT & REVIEW -2 If not reviewed within this assessment period, POLST becomes invalid! The practitioner may then do one of the following if the resident/legal surrogate decision maker agrees:  POLST will be reviewed; Complete review process documented; Include date/time of discussion, parties involved, what were discussed, any plans or action

11. ASSESSMENT & REVIEW -3 The practitioner...(cont.)  POLST will be reviewed; If no changes, place the POLST form in the medical record. The physician: Completes the review process by reviewing the POLST Signing an order to “Follow POLST Instructions”

12. ASSESSMENT & REVIEW -4 POLST reviewed with resident and/or legal surrogate decision maker  Within the first 14-day  When the resident or surrogate decision maker requests  When warranted by a substantial change  Periodically per facility policy The RN will discuss regarding the “Resuscitation – Do not Resuscitate” treatment decision

13. ASSESSMENT & REVIEW -5 Facility must do the following to ensure compliance regarding the POLST form:  Notify the physician of the DNR or resuscitation If the POLST form is incomplete, the highest level of treatment must be performed  Make a good faith effort to follow the instructions in the POLST

14. PHYSICIAN PARTICIPATION – NURSE PRACTITIONERS Must discuss with the resident and/or legal surrogate decision maker  Treatment options referred to on POLST  POLST initiated/changed If resident does not request/change or condition does not warrant consideration, it is NOT required to sign the POLST again.

15. PHYSICIAN PARTICIPATION – NURSE PRACTITIONERS -2 Admitted with POLST signed by another physician will be honored for the 14-day assessment period. If changes in treatment decisions are warranted:  The physician must review the POLST  Resident and/or legal surrogate decision maker must be informed that changes make the POLST invalid

16. PHYSICIAN PARTICIPATION – NURSE PRACTITIONERS -3 If changes in treatment decisions are warranted (cont.):  POLST with new decisions must be discussed which requires discussion between the resident and/or legal surrogate decision maker  Physician to complete new form with 14 to 30 days

17. RESIDENTS ARRIVE WITHOUT POLST Provide a POLST form for the physician and the resident / legal surrogate physician Notify the resident’s physician Physician should discuss:  Benefits  Burdens  Efficacy and appropriateness of treatment and medical interventions

18. RESIDENTS ARRIVE WITHOUT POLST -2 Healthcare provider (nurse / social worker) can explain the POLST form but the physician is responsible for discussing treatment options. Make a copy of the completed POLST form. Mark as “COPY”. File the copy in advance directive or legal section.

19. RESIDENTS ARRIVE WITHOUT POLST -3 The original POLST form will be transferred with the resident upon discharge.  Add the POLST form to the resident’s inventory  Place the original POLST form at the front of the resident’s physical chart  Update physician’s orders to reflect POLST

20. POLST & THE MEDICAL RECORD POLST will be located as the 1 st page in the Advance Directive section of the chart.  If POLST is void, draw a line through the POLST and write “VOID” in large letter, then date, sign or initial the form  Retain all voided POLST  Current original POLST must accompany the resident When resident is discharged, retain a copy of the POLST; original must accompany resident.

21. DISCHARGE RESIDENT WHO ARRIVED WITH POLST At discharge, the POLST orders must be reviewed & verified with the responsible party. Make notation on the POLST form if remained valid. If the responsible party requests changes to a POLST, a new form must be completed!

22. DISCHARGE RESIDENT WHO ARRIVED WITH POLST -2 The new POLST must be copied/scanned and original returned to the resident to carried to the next care setting. Facility must make and retain a copy (marked “COPY”) of the current POLST. If POLST conflicts with the resident’s PIC or advance directive, the most recent expression of the resident’s wishes will prevail.