You’ve Got Questions?

We’ve Got Answers

Sally Hardwick, MS Chair, Nevada POLST – A Nevada Non-Profit

Providers Training

In the Beginning

• POLST: Physician’s Order for Life-Sustaining Treatment

• Oregon POLST – 1991

• Advance Directives (ADs) provided general guidelines, but specifics were still vague

• ADs are difficult to locate

• Too long

The Oregon POLST

• Meaningful Conversation of patient wishes and treatment ramifications

• Succinctly identifies patient wishes

• Easily identifiable

• More specific treatments

• Portable medical orders

• Intended redundancy

Similarity to ADs

• Thoughtful, considered conversation with patient and loved ones

• Based on values

• Comfort measures are always provided

• Only used when unable to express themselves

Differences between the Nevada POLST Program and Other ADs

• This is not just a form, it is a program involving a discussion between providers and patients and coordination between facilities and emergency medical services

• Frail, elderly or those with serious, advanced, progressive disease

• 5 year life expectancy

• Reflects current state of health

• Medical order that travels with the patient (home, transport or facility)

• Requires physician and patient or patient’s representative’s signature and date

• Provides for an out-of-hospital DNR (residence, transporting) honored by Emergency Medical Services (EMS)

• Should indicate with whom discussed as well

• Concise

Features: Recognizable

• Nevada POLST forms are bright pink• Available at:• Order at: www.NevadaPolst.org

• Download for Educational Purposes:• Nevada State EMS:

http://health.nv.gov/PDFs/EMS/Forms/POLSTform.pdf or,

• www.NevadaPolst.org (with watermark: “SAMPLE”)

Features: Portable

POLST

Patient

EMS Facility

ASKASK

ASK

POLST Side One: Medical Orders

• Instructions• Patient Information• Section A: CPR• Section B: Other medical

interventions• Section C: Physician

documentation

POLST Side One: Medical OrdersInstructions / Patient Information

• Write the date in the date of birth box:

Ex: Feb. 12 1941

POLST Side One: Medical OrdersSection A: CPR

• EMS-DNR #: from the salmon colored card• No longer necessary; legislature approved

POLST to be honored in all settings• The salmon colored card is no longer

necessary unless someone wants it for use when away from their residence.

• POLST must be signed and dated by a physician in Section C and the patient or their agent in Section F

POLST Side One: Medical OrdersSection B: Interventions: Comfort Measures

• Relevant if:• “Allow Natural Death” marked in Section A or• Patient is not in cardiopulmonary arrest

• If checked, patient should remain at current location (home, nursing home, etc.), unless comfort cannot be achieved at this location

POLST Side One: Medical OrdersSection B: Limited Medical Interventions• Remind patient the POLST is ONLY used if they

are so sick they can’t speak for themselves.

• Explain the implications, what it may involve and how it may affect them.

• Beware of conflicting orders.

POLST Side One: Medical OrdersSection B: Interventions: Full Treatment

• Explain the implications. Explain that treatment may or may not be successful, and may result in additional discomfort.

• Discuss “Additional Instructions” - might include a trial period of treatments to determine tolerance and benefit.

POLST Side One: Medical OrdersSection C: Physician Validation• REQUIRED for validity• Signature• Date

• Other boxes• Very helpful should there be any question of validity• Printing template at www.nevadapolst.org

/nevada-polst-form/printing-instructions/ Printing Repetitive Information for Section C

• Transfer Reminder

POLST Side Two: Patient Preferences

• Organ Donation

• AD Information: Summary of information in patient’s Living Will, Declaration and/or Durable Power Of Attorney (DPOA)

• Conversation documentation

• LivingWillLockbox.com information

• General Instructions

POLST Side Two: Patient PreferencesSection D: Organ Donation

• Name and Date of Birth – Verify with patient bracelet

• Checking Section D box does NOT give authorization for organ donation; check their NV State issued ID to verify

POLST Side Two: Patient PreferencesSection E: Advance Directive Summary

• If AD available, complete this section!• If AD is registered with the Secretary of State,

LivingWillLockbox.com, patient may have an ID card available

• #2 – State law provides an order of authority for resuscitation orders only.

POLST Side Two: Patient PreferencesSection F: Signatures• Circle the responsible party with whom you

have spoken regarding the POLST• Agent is the person specified in the patient’s Durable

Power of Attorney for Health Care (DPOA)• Patient or their representative MUST sign and

date it• Consent with witness will reduce confusion and

conflict when POLST is needed• Preparer may be physician (required for Side 1),

nurse or social worker

POLST Side Two: Patient PreferencesSection G: Registry• Registry is the Secretary of State’s

LivingWillLockbox.com (LWL)• Your facility and/or office should:• Be registered for access to Livingwilllockbox.com

• Have a supply of authorization forms on hand

• Have a process in place to assure POLSTs and ADs are registered

• Offer both POLST and LWL authorization form at patient interview

• When signed, or at least explained, initial box

POLST Side Two: Patient PreferencesSection G Alternative

• The use of Health Information Exchanges (HIE) assure patient information is available across health care settings and between providers

• HealthInsight offers HealtHIE Nevada for this purpose.

• ADs, POLST and other patient medical information can be accessed on HealtHIE Nevada

• A significant number of providers, labs, pharmacies, etc. have already begun uploading records.

• For more information: http://www.healthienevada.org/

Reimbursement Codes

• Out-Patient Consultations• Wellness codes• Fewer than 10% of providers are utilizing wellness

codes.• Provides an opportunity to review medications,

past history and end-of-life considerations

• In-Patient Consultations• CPT II codes

• NevadaPOLST.org/billing-for-polst-consultation/

What are the Legal Implications of POLST

• POLST is a state approved form (AB344)

• You cannot be disciplined or face legal action if:• Treatment is withheld in compliance with the

POLST form and the medical orders reflected on it;• The provider is unaware of the existence of a

POLST; or,• The patient, their agent, parent or legal guardian

over-rides it (Any of these may over-ride a POLST form)

Physician Authority and Priveleges

• Health care providers shall comply with a valid POLST regardless of whether the physician who signed the POLST:• Has authority during transport or• Has privileges at the receiving facility

Physician Responsibility

• A POLST should be completed for a patient if:• Their life expectancy is less than 5 years; and,• They have a terminal illness or are very frail; or,• They request one

• In these instances, the physician shall explain:• The availability of the POLST;• The features and procedures offered by it; and,• The difference between the POLST and other

ADs

Reviewing and Revising the POLST• A POLST should be reviewed when

the patient:• Is transferred from one care setting or level

to another;• Has a substantial change in health status; or,• Preferences change

• When a POLST needs to be revised due to wear/tear or change of orders or other information• Write VOID diagonally across both sides of

the POLST and place in the patient’s chart• Complete a new POLST, sign and date it

Conflicting Documents

• Should an AD and POLST conflict, the most recent one will be considered valid.

• If a patient has a POLST that directs CPR be given to a patient with a valid DNR identification, CPR shall not be provided if the ID is with the patient regardless of which is more recent.

• IF A PATIENT HAS A DNR ID THAT CONFLICTS WITH THEIR POLST, determine which treatment they wish, then complete a POLST reflecting those orders. Ask the patient to destroy their DNR card to avoid confusion.

Compliance with POLST

• Should a physician or other health care provider be unwilling to comply with the directives of the POLST, all reasonable measure shall be taken to transfer to a compliant facility.

• If a patient is known be pregnant, so long as it is probable that the fetus will develop to the point of live birth with application of life-sustaining treatment, life-sustaining measures shall be attempted.

Blank Sections and Other States’ POLSTs

• Any completed section is valid unless the POLST is not signed and dated by a physician (Section C) and the patient or the patient’s representative (Section F).

• Blank sections should be presumed to indicate full treatment, unless it conflicts with a completed section.

• A valid POLST (MOST, POST, MOLST) of another state shall be honored in Nevada.

Journal of the American Geriatric Association (JAG)

• Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon

• Published Online June 9, 2014 – Available soon in June issue of JAG

• 17,902 subjects – largest study to date

RESEARCH

RESEARCH – POLST Preferences and Hospital Deaths

• POLST Preferences• Comfort Measures Only – 66.1%• Limited Interventions – 26.7%• Full Treatment – 6.4%

• Association between POLST Choices and Hospital Deaths:• Comfort Measures Only – 6.4%• Limited Interventions – 22.4%• Full Treatment – 44.2%

• For those without a POLST – 34.2% were hospitalized

RESEARCH – POLST Preferences and Hospital Deaths

• Take Away Message

• Vastly more who complete a POLST choose CMO

• Those with POLSTs for CMO were significantly LESS likely to die in a hospital

• Those with orders for full treatment were MORE likely to die in the hospital than those without a POLST

• This holds for each of the top 10 causes of death.

• End-of-life preferences to avoid hospitalization as documented in POLST orders are honored

ResearchJAGS, Volume 58 Issue 7, 2010

• Stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia, 1711 living & deceased subjects.

• Residents with POLSTs were more likely to have orders regarding life-sustaining treatment other than CPR (98.0% vs 16.1%, P<.001).

• POLST was more effective than traditional practices at limiting life-sustaining medical interventions residents did not want

• Residents with POLST forms requesting comfort measures only were less likely to receive medical interventions (e.g., hospitalization), (P=.004), than residents with traditional DNR orders (P<.001), or residents with traditional full code orders (P<.001).

Nevada POLST

Nevada POLST is a Nevada non-profit formed specifically to:• Educate and train the public and health care

providers regarding the Nevada POLST Program• Provide state approved Nevada POLST forms…

bright pink, 65# stock• Support other organizations in providing

compassionate end-of-life care

For more information visit www.nevadapolst.org