Faculty Disclosure POLST Discussions Doing it Better Clinical Update in Geriatric Medicine Dr. Black discloses that she is employed by Allegheny Health Network and is an executive committee member of the National POLST Paradigm Task Force. Judith S. Black, MD, MHA April 9, 2016 Page 2 Objectives PART I At the end of this sessions, participants will be able to: Define the role of POLST in Advance Care Planning POLST Overview Apply tools and resources to enhance skill and comfort when engaging in goal of care discussions Integrate understanding of the role of the surrogate in POLST decision-making Page 3 Page 4 Purpose of POLST To provide a process to determine and communicate patient preferences for end-of-life treatment across treatment settings. Differences Between POLST and Advance Directives Characteristics POLST Advance Directives 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 Provider responsibility Patient/family responsibility Page 5 Page 6
Providing a Uniform Message POLST is designed to honor the freedom of persons with advanced illness or frailty to have or to limit medical treatment across settings of care. POLST Is For Seriously ill patients Terminally ill patients Patients with advanced frailty Anyone with advanced age wishing to further define their preferences for care POLST is a voluntary process and: Unless it is the patient s preference, use of the POLST form is not appropriate for persons with stable medical or functionality problems who have many years of life expectancy. Page 7 Page 8 Where Does POLST Fit In? Pennsylvania Form Advance Care Planning Continuum Age 18 Complete an Advance Directive Update Advance Directive Periodically Diagnosed with Advanced Illness or a Serious Health Condition (at any age)or Medical Frailty* Complete a POLST Form Page 9 *Someone for whom you would not be surprised if they died within a year Treatment Wishes Honored Page 10 POLST Script - Section B Medical Interventions Pennsylvania Form, 2 nd Side CPR Comfort Measures Limited Interventions Full Treatment* DNR *Consider time/prognosis factors under Full Treatment. Example: Defined trial period. Do not keep on prolonged life support. Material used with permission from the Coalition for Compassionate Care of California, www.coalitionccc.org Page 11 Page 12
POLST Form Requirements The minimum requirements for completion and acceptance as a medical order are: Patient name Completion of Section A - Resuscitation orders Completion of Section E 1. Clinician signature A physician, CRNP or physician assistant* 2. Patient or legal decision-maker signature All other information is optional. Review of POLST Form The POLST Form should be reviewed and a new form completed if necessary when: The person is transferred from one care setting to another There is a substantial change in the person s health status The person s treatment preferences change The goal is always that treatment wishes are honored! (*In PA, must be co-signed by a physician within 10 days) Page 13 Page 14 PART II The POLST CONVERSATION Document is NOT the main thing! The POLST form is an essential element of a system to document and transmit patient care preferences, but is NOT the main thing Careful facilitated discussions that elicit care preferences ARE the main thing! Page 15 Page 16 Patient and Family Brochure To help prepare patient and family, you may want to provide a copy of the POLST form and this brochure in advance of the conversation. If conversation is with patient, make sure family aware of POLST and medical orders. POLST Conversation Tools Helpful Phrases for Conversations Serious Illness Conversation Guide Patient and Family Brochure Cue Card Alternate Facilitator Documentation POLST in Action in Pennsylvania Page 17 Page 18
8-Step Protocol For Discussing POLST 1. Prepare for the discussion 2. Begin with what the patient or family knows 3. Provide any new information about the patient s condition and values from medical team perspective 4. Try to reconcile differences in terms of prognosis, goals, hopes and expectations 5. Respond empathetically 6. Use POLST to guide choices and finalize resident/family wishes 7. Complete and sign POLST 8. Review and revise periodically Page 19 Protocol was originally developed by Dr. Pat Bomba for the MOLST Program of New York State. Program information is found at www.compassionandsupport.org Page 20 PART III POLST Cases Page 21 Page 22 Case 1 Hospital Discharge 70 year old single man and no children is being discharged from hospital to nursing home following treatment for head trauma as a result of a motor vehicle accident. Determined to be permanently unconscious. He has no advance directive. His two sisters meet with palliative care doctor for goals of care discussion and completion of POLST form. Who can sign his POLST form? Can the decision-maker choose DNR and Comfort Care Only? 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 Page 23 Page 24 *Copyright 2012 Robert B. Wolf, Esquire
Case 2 Hospital Inpatient, Revoking a POLST 72 year old female with dementia presents with gangrenous cholecystitis. Despite surgery and maximal critical care treatment, patient develops multi-organ system failure Early in the patient s diagnosis of dementia, she and her PCP had filled out a POLST document calling for full treatment measures Son, who is health care power-of-attorney, regrets that POLST was never updated and believes patient would want palliative/hospice care measures at this stage Is it appropriate for health care providers to follow the son s guidance under these circumstances? Who is the Pennsylvania Decision-Make 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 Incompetent Patient Yes, if for revoking withholding or withdrawing life sustaining *Copyright 2012 Robert B. Wolf, Esquire Page 25 Page 26 Case 3 - Hospital Inpatient 89 year old male with advanced emphysema, peripheral vascular disease and other chronic conditions, but not imminently terminal. Had two short intubations in past; survived to go home. Does not want CPR, but would like a trial of intubation, would try up to a week. How should his preferences be reflected when you complete his POLST form? Case 4 - Nursing Home You are preparing for a family meeting of Mr. Jones, a newly admitted 92 year old male with Alzheimer s Disease. He has severe contractures and is bedridden. He was admitted yesterday for aspiration pneumonia. His POLST states: Section A, Attempt Resuscitation Section B, Full Treatment How will you address his POLST during the family meeting? Page 27 Page 28 Case 5 Nursing Home Your patient is 86 years old with moderate to severe dementia, mild hypertension, and a history of osteoarthritis with hip and knee pain. The patient does not have decision making capacity. You are introducing the patient s daughter to POLST. The daughter states, I know that she would not want any of this, but I feel like I have to do this. What can you say to the daughter? What questions can you ask her? Case 6 - Hospice 82 year old woman in nursing home is receiving hospice care. Upon admission to hospice, she completed and signed a POLST form with the choice of Comfort Measures Only. One week later, she sustained a fall in the nursing home and has a probable hip fracture and closed head trauma. Should EMS be called? Page 29 Page 30
Case 5 - Same Hospice Patient Case 6 Any Facility Type As EMS arrives, the patient becomes unresponsive, is found to have no pulse or respirations. What does EMS do? You are reviewing the POLST of a newly admitted patient. The POLST states: Section A: Attempt Resuscitation Section B: Comfort Measures Only Section C: Use Antibiotics if life can be prolonged Section D: Long-term artificial nutrition, including feeding tube Is anything wrong with this? What would you do next? 31 Page 32 Take Away Points Skill and comfort with the discussion can be improved with practice and help of many available tools In your practice: Develop processes to ensure that conversations are occurring Leverage the Annual Wellness Visit Identify triggers within your EMR to have a more in depth conversation Assure conversations are occurring with appropriate decision-maker Have the conversation with your patients, your family and loved ones Page 33 Page 34 POLST Website Resources www.aging.pitt.edu/professionals/resources.htm www.polst.org www.portal.state.pa.us/portal/server.pt/com munity/emergency_medical_services/14138 /polst_out-of-hospital_dnr_orders/556979 Aging Institute of UPMC Senior Services and the University of Pittsburgh Center for Ethics in Health Care Oregon Health & Science University Pennsylvania Department of Health Bureau of Emergency Medical Services Out-of-Hospital DNR Information OOH_DNR BLS Statewide Protocols QUESTIONS? Judith S. Black, MD, MHA Medical Director Geriatric Service Line of Allegheny Health Network jblack3@wpahs.org www.wvendoflife.org www.compassionandsupport.org/ www.compassionandsupport.org West Virginia Center for End-of-Life Care POST New York State MOLST, Excellus Blue Cross Blue Shield Coalition for Compassionate Care of California Marian Kemp, RN POLST Coordinator Coalition for Quality at the End of Life (CQEL) papolst@verizon.net Page 35 Page 36