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POLST Education for Healthcare ProfessionalsHospice and Palliative Nurses Association (HPNA) E‐Learning

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POLST (Physicians Orders for Life Sustaining Treatment)

Education forHealthcare Professionals

Presented byNancy 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 POLST3. Describe differences between Healthcare

Directives and POLST


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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 optionso Level of life sustaining treatmento 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


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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


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POLST is Spreading ( 2007)11 states

•Oregon •Washington•Georgia •Kansas •Missouri •New Mexico •Utah •West Virginia•Wisconsin•New York•Pennsylvania

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2009‐ 34 states

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2011‐ All But 9 States

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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 life‐sustaining 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 care5. 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


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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 conditiono their prognosiso 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


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Reviewing Goals, Treatment Priorities

•Goals guide care

•Assess priorities to develop initial plan of care

•Review with any change ino Health statuso Advancing illnesso Setting of careo Treatment preferences


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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 requesto Patient’s best interesto Patient’s known preferenceo Medical futility of treatment (non‐beneficial)o CARE is never futile


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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

OfficePre-hospital& acute care


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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 lawo Out‐of‐hospital DNR protocols o Limitations on consent to forgo life‐sustaining treatment


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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


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POLST: A National InitiativeRecognized/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 directiveo POLST