FINE TUNING THE POLST SYSTEM: THE CASE OF AN INVALID, CONTRADICTORY POLST FORM

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FINE TUNING THE POLST SYSTEM THE CASE OF AN
INVALID, CONTRADICTORY POLST FORM
Alvin (Woody) Moss MD, WVU Center for Health
Ethics and Law Margaret Carley JD, RN OHSU
Center for Ethics in Health Care        Terri
Schmidt MD, MS, Oregon Health Science
University (EMS) Paul Schneider MD, VA Medical
Center, Los Angeles, CA Kenneth Zeri RN, MS,
Hospice Hawaii
National POLST Paradigm Task Force members
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Current as of January 3, 2012
www.polst.org
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• A 78 year-old woman was admitted from a
  nursing home with chest pain. She had a past
  history of coronary artery disease status post
  stent placement, congestive heart failure,
  hypertension, lipid disorder, and mild dementia.
  A POLST form accompanied the patient and
  indicated CPR in Section A and limited additional
  interventions in Section B. The attending
  physician wondered what he should do with the
  POLST form because Section A and Section B seemed
  to be contradictory. The POLST form had been
  prepared by a social worker who had signed it,
  but there was no physician signature on it.

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• In transporting the patient, EMS worried,
  What do I do if she codes and I do CPR and get
  her back, but she is not breathing normally? Do I
  intubate her? The ED physician wondered the same
  thing, but fortunately she did not suffer a
  cardiac arrest.
• When interviewed by the palliative care
  team who was consulted to address the POLST form
  inconsistency, the patient indicated that she
  would not want to be kept alive on machines and
  when it was explained to her that if she had CPR
  and lived through it, it was very likely that she
  would end up being on a breathing machine. She
  said, Well then, I dont want CPR.

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• The patient was questioned, and she clearly
  understood that without CPR in the event of a
  cardiorespiratory arrest she would die. She was
  felt to have decision-making capacity for her
  decision. A daughter who lived out of state was
  the patients Medical Power of Attorney
  representative and wanted her mother to have CPR.
• What should be done with regard to the
  seemingly contradictory POLST form and the
  conflict between the patient and her daughter?
  How could these situations be prevented in the
  future?

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Where Was the Problem in This Case?

• Can we expect POLST preparation to be any more
  accurate/functional than the rest of our somewhat
  inaccurate/dysfunctional system? If so, how?
  Who should own POLST and what control should
  they exert?
• In code discussions, when will providers
  demonstrate the moral courage to use the word
  die? If God forbid you were to die during
  this hospitalization, would you want us to try to
  bring you back from death?

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Where Was the Problem in This Case?

• What was the role of the physician in this case?
  The SCBCC struggled mightily over this question
  and concluded physicians must at least personally
  confirm the discussion when initially prepared by
  a non-physician. My hospital mandates an MD
  POLST discussion. VA does not allow resident,
  licensed physicians to sign DNR orders gt 24 hrs.
  Therefore, they should not sign most POLSTs.

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Does the patient have capacity ?

• Does the patient have capacity
• How, when and who would make this determination
  this in your state?
• When can the appointed health care
  representatives begin to make health care
  decisions?
• What happens if the patient does not have
  capacity and there is no one available to make
  health care decisions?

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Can a family member override the existing POLST
Orders?

• State by state variations attributable to
  different advance directives and surrogate
  decision maker statutes
• May depend on if your POLST program is statutory,
  regulatory or voluntary
• Outside the hospital it may depend on your
  out-of-hospital DNR statute or rules
• May depend upon statutory or regulatory
  limitations based on the clients medical
  conditions

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May Be Multiple Family Member Roles

• Informal roles of family members
• Primary Caregiver
• Primary Decision Maker
• Spokesperson
• Out-of-Towner
• Patient Wishes Expert
• Protector/Vulnerable Member
• Health Care Expert
• End-of-Life Decision Making in Adult ICUs Roles
  Relationships of Key Players
• Judith Gedney Baggs, PhD, RN, FAAN

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Minimizing or avoiding conflicts by a better
goals of care conversation

• Advance Care planning
• Goals of Care
• Communication
• What do patients and families want?
• Better communication by clinicians
• Timely, on-going, clear, complete, compassionate
• Address condition, prognosis, treatments
• Patient-focused health care decision making
• Aligned with patient values, care goals,
  preferences

Nelson, Puntillo, et al. (2010), In their own
words. Critical Care Medicine
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.Was this a burdensome transition of care from
nursing home to hospital?

• Health care transitions, such as the
  hospitalization of nursing home residents, have
  the potential for fragmentation of care, changes
  in the management of chronic diseases,
  duplication of diagnostic workups, and medical
  errors.
• NEJM Study Results
• Among 474,829 nursing home decedents, 19.0 had
  at least one burdensome transition(range, 2.1 in
  Alaska to 37.5 in Louisiana).
• In adjusted analyses, blacks, Hispanics, and
  those without an advance directive were at
  increased risk.
• Nursing home residents in regions in the highest
  quintile of burdensome transitions (as compared
  with those in the lowest quintile) were
  significantly more likely to have a feeding tube,
  have spent time in an ICU in the last month of
  life have a stage IV decubitus ulcer , or have
  had a late enrollment in hospice.

Gozalo P, Teno JM, Mitchell SL, et al.
End-of-Life Transitions among Nursing
Home Residents with Cognitive Issues. N Engl J
Med 20113651212-21.
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EMS

• Conflicting Section A and B orders
• Section A DNR Section B Full Treatment
• Section A Resus Section B Comfort Measures
• Section A Resus Section B Limited Interventions
• What should EMS do?

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What is the trump card?

• POLST form
• Patient choice
• Family/surrogate choice (Does it matter if it is
  a legal guardian? Power of attorney for health
  care?)

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Hospice Care

• Staff must know basic laws governing POLST in
  state
• Hospice care across most settings
• Home, SNF, Hospital, Care Home, Hospice Facility,
  Homeless
• POLST Form may be voluntary for healthcare
  institutions to use, but POLST Orders may be
  mandatory to follow
• Legal requirements for correct document

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Hospice Care

• Home based care
• Clarifying goals for care
• Including family
• Policies regarding completing forms
• Nursing Facility / Hospice Collaboration
• Support Facility staff in review clarification
  of POLST
• Hospice team (MD, RN, MSW) support resolution of
  conflict
• Policies governing use of form
• POLST is voluntary

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Regional lunch discussions
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Regions

• California Aviary Ballroom
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