POLST (Physicians Orders for Life Sustaining Treatment) Education for Healthcare Professionals Presented by Nancy Joyner, APRN CNS, ACHPN Disclosure Nancy Joyner does not have any financial, professional or personal conflict of interest Nancy s presentation will not refer to products, drugs or devices of a commercial company with which I have a significant relationship Nancy has not accepted a fee from a commercial company for this presentation Objectives 1. Identify what POLST is and who should have POLST 2. Discuss the key elements of the POLST 3. Describe differences between Healthcare Directives and POLST 1
Realities Life expectancy increased Increased prevalence of chronic disease Increased comorbidities and frailty advancing age Changing families, healthcare systems, society and marketplace demands Death becomes optional Philosophy of POLST Individual s right health care decisions Decisions include: o Life sustaining treatment options o Level of life sustaining treatment o Comfort care AND having wishes honored What is the POLST Paradigm Medical order Provides consistent information Recognized document A mechanism to communicate patient preferences Used across treatment settings 2
Healthcare Directive or POLST? Healthcare Directive For anyone 18 and older Provides instructions for future treatment Appoints a health care representative Does not guide emergency medical personnel Guides inpatient treatment decisions when made available POLST For seriously ill/frail, at any age Provides medical orders for current treatment Guides actions by emergency medical personnel when made available Guides inpatient treatment decisions when made available Limitations of Healthcare Directives/ Advance Directives (AD) Not available or known Not completed by most adults Not transferred Not specific enough May be overridden by a provider Do not translate into medical order Used only when patient/resident unable Used only under certain delineations Development of POLST Consensus development Began in 1991 Ongoing revision process Voluntary process in Oregon National POLST Advisory panel 3
POLST is Spreading ( 2007) 11 states Oregon Washington Georgia Kansas Missouri New Mexico Utah West Virginia Wisconsin New York Pennsylvania 2009 34 states 11 2011 All But 9 States 12 4
13 POLST Paradigm Mission (what is success) o To facilitate POLST Paradigm Programs in every state Vision (what drives us): o To ensure that seriously ill person's wishes regarding lifesustaining treatments are known, communicated, and honored across all health care settings Objectives (what we are doing): 1. To facilitate the development, implementation and evaluation of POLST Paradigm Programs in the U.S 2. To educate the public and health care professionals regarding the POLST Paradigm 3. To support, perform, and fund research related to end of life care 4. To improve the quality of end of life care 5. http://www.ohsu.edu/polst/about/index.htm Why have POLST? Improves the quality of care Provides effective communication of patient wishes Documents medical orders on a specific form Promise to honor these wishes Ensures decisions are patient specific 5
Continuity of POLST orders Consistent color identified Accuracy Flexibility Portability Availability Legal standing emergency medical technicians Patient Centered Care Advanced Care Planning Effective communication Involves patient (or legally designated decision maker) and health care professionals Ensures decisions are sound Based on the patient s understanding of o their medical condition o their prognosis o the benefits and burdens of treatment o their personal goals for care Hope, Goals, Expectations Hope, goals, expectations change with illness Physician s role to clarify goals, treatment plan Team member s role = support patient s goals Some take precedence over others Gradual shift in focus of care Expected part of the continuum of medical care HPNA Position Statement The Nurse s Role in Advance Care Planning ANA Position Statement Nursing Care and DNR Decisions 6
Reviewing Goals, Treatment Priorities Goals guide care Assess priorities to develop initial plan of care Review with any change in o Health status o Advancing illness o Setting of care o Treatment preferences 7
Spiritual & Cultural Perspectives POLST supports patient autonomy POLST is consistent with the Catholic moral tradition POLST is appropriate in: o Chronic or critical illness o Advanced illness About not simply to forgo life sustaining treatment Addresses inherent dignity of the person Essential in every personal encounter Expressed differently in each encounter Who Should Have A POLST? Patients with multiple co morbidities Patients with serious, life limiting disease Patients who may not survive another year Some patients in ICU, critical care, emergent situations Others? Basis of POLST Discussion with patient Discussion with surrogate decision maker Patient centered decision: o Patient s request o Patient s best interest o Patient s known preference o Medical futility of treatment (non beneficial) o CARE is never futile 8
Initiating POLST Introduced/discussed with patient and family by a physician, nurse, social worker, or chaplain Must be signed by physician, nurse practitioner, or physician s assistant Must be signed by patient or proxy Where can POLST be initiated? Long term care Pre-hospital & acute care Office 9
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Barriers to POLST Legal Issues (State statutes and regulations) o Living wills o Durable power of attorney for health care o Default surrogate provisions o Guardianship law o Out of hospital DNR protocols o Limitations on consent to forgo life sustaining treatment 12
Barriers to POLST Education Buy in Settings Policy, rules of institutions POLST versus Advance Directive True or False A POLST form is only for adult patients A POLST form needs to be signed by the physician and patient/decision maker An advance directive can direct medical personnel A person s wishes are always known with a POLST True or False A POLST form is kept on the patient s medical record in the physician s order section An Advance Directive goes into effect with each hospitalization With a POLST the decision maker signs, not the patient An Advance Directive should be done in a lawyer s office A POLST form goes into effect when the patient is unresponsive 13
POLST: A National Initiative Recognized/Endorsed by National Agencies Center to Advance Palliative Care (CAPC) End of Life/Palliative Education Resource Center (EPERC) Institute for Clinical Systems Improvement (ICSI) Institute of Medicine (IOM) National Hospice and Palliative Care Organization (NHPCO) POLST National Website POLST.ORG Physicians Orders for Life Sustaining Treatment Paradigm Google: POLST POLST Summary Educate, encourage, communicate and advocate Advance care planning discussion Patient s wishes Documentation o Healthcare directive o POLST 14