CCRMC Introduction to POLST

CCRMC Introduction to POLST

Ray Jarvis VITAS

Forrest Beaty MD

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If you are dying in Miami, the last 6 months of your life might well look like…

You’ll see a physician, mostly specialists 46X Spend more than six days in ICU Stand a 27% chance of dying in the hospital The bill for physician / hospital care will be

> $23,000

Medicare Analysis Dartmouth Medical School

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You’ll visit your doctor 18 times 50% of those visits will be with your PCP One day in the ICU 13% chance of dying in the hospital More likely to die at home on hospice Bill for hospital / physician care $14,000

If you are dying in Portland, OR, the last 6 months of your life might well look like…

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End of life facts

27% of Medicare’s annual $327 billion budget goes to care for patients in their final year of life.

> 80% of respondents said they would like to die at home, surrounded by family and friends.

Approximately 70% of Americans die in health care facilities (55% hospital, 16% in LTC)

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How can we reduce the mismatch between patient wishes and reality?

What can we do to ensure patient’s end of life care wishes are honored?

What is POLST?

PhysicianOrders for LifeSustainingTreatment

California POLST Education Program© May 2009 California Coalition for Compassionate CareMaterials made possible by a grant from the California HealthCare Foundation

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Why POLST?

1. Patient wishes often are not known. The Advance Health Care Directive (AHCD) may not be accessible, clear, or honored.

2. Allows healthcare professionals to know wishes for end-of-life care and honor them.


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Case Study: What We Know

Mr. Jones, an 83 year old man with severe chronic obstructive pulmonary disease (COPD) and mild dementia.

In skilled nursing facility (SNF) after hospital stay for pneumonia.

Developed increased shortness of breath and decreased responsiveness.

SNF called Emergency Medical System who transported patient to hospital.


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Case Study: What We Know

Emergency Room physician could not find any code status information in SNF papers.

Wrote “Full Code for now, status unclear.” Mr. Jones was intubated and transferred

to the ICU.


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Case Study: What We Didn’t Know

Mr. Jones had an AHCD. It was at his home so the SNF couldn’t send it to the hospital.

Mr. Jones had talked with his family and SNF staff about his desire not to go back to the hospital and receive aggressive treatment.

There was no documentation of the conversation to alert the ED staff.

The weekend nurses at the SNF could not reach his family and did not know about his wishes.


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Case Study: What Went Wrong

AHCD not transferred with patient. DNR wishes not documented. Over-treatment against patient wishes. Unnecessary pain and suffering. System-wide failure to document and

honor patient wishes.


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What is POLST?

A physician order recognized throughout the medical system.

Portable document that transfers with the patient.

Provides direction for a range of end-of-life medical treatments.

Brightly colored, standardized form for entire state of CA.


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Who Needs POLST?

Chronic, progressive illness Serious health condition Medically frail Tool for determination

• “You wouldn’t be surprised if this patient died within the next year.”


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POLST History

POLST development began in Oregon in 1991.

Initially for SNF patients transferred from one care setting to another.

Use of POLST now expanded to more than 23 states.

Oregon study of 180 SNF patients – POLST stated: No CPR and Comfort Measures Only. Patient wishes were honored.

Developing ProgramsDeveloping Programs*As of February 2009

National POLST Paradigm Initiative Programs

Established ProgramsEstablished Programs

No Program (Contacts)No Program (Contacts)Designation of POLST Paradigm Program status based on information available by the program to the Task Force.


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POLST in California

California Coalition for Compassionate Care (CCCC) is lead agency with support from California HealthCare Foundation

CA Assembly Bill 3000 Effective January 1, 2009 One form for entire state Use not mandated Honoring form is mandated


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Does POLST Replace the Advance Health Care Directive?

POLST does not replace the Advance Health Care Directive (AHCD).

AHCD allows you to name a health care decisionmaker if in the future you are unable to communicate wishes.

Encourage everyone 18 years and older to complete an AHCD.


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Where Does POLST Fit In?

Advance Care Planning Continuum

Complete an Advance Directive

Complete a POLST Form

Age 18

End-of-Life Wishes Honored

Diagnosed with Serious or Chronic, Progressive Illness (at any age)

Update Advance Directive Periodically

CC OO NN VV EE RR SS AA TT II OO NN


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POLST vs. Pre-Hospital DNR(Do Not Resuscitate)

POLST and Pre-Hospital DNR:• Physician orders• Address Do Not Resuscitate• Medically frail or those with chronic or serious illness

POLST:• Allows for choosing resuscitation• Other life-sustaining treatments• Honored across all healthcare settings

Pre-Hospital DNR:• Honored outside hospital only (home, assisted living,

SNF, EMS system)


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POLST vs. PIC(Preferred Intensity of Care)

Both include choices for medical interventions

PIC forms are not medical orders and do not transfer to other settings

POLST can replace the PIC form at SNF


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Section B: Medical Interventions

CPR

Full Treatment*

DNR

Comfort Measures

Limited Treatment

*Consider time/prognosis factors under “Full Treatment” “Not to be kept on life support if not expected to recover.”


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Who Can Speak for the Patient

Agent/surrogate decisionmaker Parent, guardian, conservator Closest available relative


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When to Review POLST

Patient’s treatment preferences change. Change in patient’s health condition. Transfer from one care setting to another. Patient Care Conference.


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Can POLST be Changed?

Individual with capacity can change the POLST at any time.

A health care decisionmaker may request a change to POLST based on a condition change or new information regarding patient wishes if patient lacks capacity.

If care is medically ineffective or contrary to accepted health care standards.


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POLST: Depth of the Process

POLST is not just a form. POLST facilitates rich conversations which

integrate patients’ values and preferred preferences for treatment.

POLST is not an Advance Directive, but part of POLST completion is encouraging completion of an AHCD.

POLST incorporates the depth of comfort care which applies to everyone.


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California POLST Project

C alifornia

The California Coalition for Compassionate Care (CCCC) providesleadership and oversight for POLST outreach activities in California, with support from the California HealthCare Foundation.

C oalition for

C ompassionate

C are


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POLST Conversation

A rich conversation with each individual patient

Comprehensive Education

To promote excellent conversational skills with patients and families

Consistent Form

Standardized form recognized across care settings

Translating an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for medical treatment.

Community Collaboration

Integrating POLST into the community standard of care

California POLST Project


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California POLST Form

Available at www.capolst.org Print on pulsar pink, 65# card stock paper Copies are acceptable Focus on the conversation


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POLST Resources

Provider and consumer brochures Frequently Asked Questions (FAQs) Guidebook for healthcare professionals Model policies and procedures Standardized educational curriculum Local POLST coalitions www.capolst.org


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Model Policy for Skilled Nursing Facilities

The purpose of this policy is to define a process for skilled nursing facilities to follow when a resident is admitted with a Physician Orders for Life Sustaining Treatment (POLST).

This policy also outlines procedures regarding the completion of a POLST form by a resident and the steps necessary when reviewing or revising a POLST form.


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Other Resources

Questions you might want to ask Facilitating Care Conferences and Family

Meetings POLST Cue Card “I Love You Mom” conversation guide

www finalchoices.org


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Where Do We Go From Here?

Dr Beaty’s clinical perspective Train SW, RNs and case managers to have

the “conversation” Implement in your facility Train personnel to be POLST proactive

Documents

CCRMC Introduction to POLST