Physician Orders for Life-Sustaining Treatment Information for Emergency Medical Services, Physicians and Hospital Staff

1
Physician Orders for Life-Sustaining
TreatmentInformation for Emergency Medical
Services, Physicians and Hospital Staff
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Physician Orders for Life-Sustaining
Treatment (POLST)

• Objectives
• Review the history of POLST and current National
  POLST Paradigm Programs
• Identify the similarities and differences between
  POLST and other advance directives
• Review pertinent NV POLST legislation
• Identify the unique features of NV POLST and
  where healthcare providers can locate the NV
  POLST forms
• Review that POLST is honored in any healthcare
  setting and in the field by healthcare providers
  and by Emergency Medical Services

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Physician Orders for Life-Sustaining Treatment
(POLST)

• Objectives (continued)
• Review physician responsibility regarding
  initiating NV POLST
• Identify when POLST forms may be revised or
  revoked
• Review when POLST conflicts with other advance
  directives
• Review the healthcare providers responsibilities
  when a patient with a POLST form is discharged

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Physician Orders for Life-Sustaining Treatment
(POLST)

• The National POLST Paradigm originated in Oregon
  in 1991
• POLST creators found that traditional advance
  directives were vague, too long, and were
  difficult to locate
• The newly created POLST forms succinctly
  identified patient wishes, were easily
  identifiable, described specific treatments, were
  portable from one setting to another and were
  enacted only after the patient and physician had
  a meaningful discussion about options and patient
  wishes for end of life care.
  (Source www.POLST.org)

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POLST Paradigm (as of December 2013)
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Nevada POLST
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Nevada POLST

• The Nevada Legislature unanimously approved POLST
  and the law went into effect October 1, 2013.
  (AB344)
• The Nevada POLST Coalition developed a POLST form
  and the Nevada Board of Health approved a
  state-wide POLST form in January 2014.
• Winter 2013-Spring 2014 The Nevada POLST
  Coalition and the Nevada Hospital Association
  developed education and tools for physicians,
  hospital staff, and emergency medical services
  staff, as well as developed media releases to
  promote POLST to Nevadas communities.

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POLST Advance Directive Similarities

• Both documents
• Are based on values and are initiated after
  conversations are held with the patient and loved
  ones.
• Are based on patient wishes, medical orders and a
  promise by healthcare providers to honor these
  wishes.
• Address comfort measures
• Are only invoked when the patient is unable to
  express treatment wishes themselves.

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POLST Advance Directive Differences

• The POLST form is concise and provides directions
  to healthcare providers on the specific treatment
  desired by the patient after they have discussed
  their options with their physician
• POLST is introduced by physicians when they are
  caring for
• frail elderly patients, or those patients with
  serious, advanced, progressive diseases
• Patients with a 5 year life expectancy or less
• A patient may also request a POLST discussion
  and completion of a POLST form

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POLST Advance Directive Differences (contd)

• POLST reflects the patients current state of
  health
• POLST travels with the patient to any setting,
  including their residence or while transporting
  from one setting to another
• It provides for an out-of-hospital DNR to be
  honored by Emergency Medical Services (EMS)
• It requires a physician signature and date
• The form does not need to be signed by patient,
  but the form should indicate who held the
  discussion with the physician

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Nevada POLST Features
Patient

• POLST

ASK
ASK
Facility
EMS
ASK

• Should be printed on hot pink stock paper (if
  available)

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Nevada POLST Features

• The POLST form is available at many sites
• NVPOLST.com (after March 15, 2014)
• Nevada State Medical Society website nsma.org
• Secretary of State LivingwillLockbox.org
• Nevada State EMS http//health.nv.gov/PDFs/EMS/For
  ms/POLST form
• At Sunrise Hospital
• Forms Fast under the ADM or CM Cabinets

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Nevada POLST Side One Medical Orders

• Instructions
• Patient Information
• CPR
• Other medical interventions
• Physician documentation

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Nevada POLST Side One Medical Orders
Instructions Patient Information
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Nevada POLST Side One Medical Orders Section
A CPR

• The EMS- DNR from the salmon-colored card is
  no longer necessary
• Because the legislature approved POLST to be
  honored across all settings
• Unless someone wants to use it when away from
  their residence

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Nevada POLST Side One Medical Orders Section
B Interventions Comfort Measures

• This section is relevant if
• Attempt Resuscitation (CPR) is checked/marked
  in Section A,or
• The patient is not in cardiopulmonary arrest
• If checked, the patient should remain at their
  current location (home, nursing home, etc.)
  unless comfort cannot be achieved at this
  location.

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Nevada POLST Side One Medical Orders Section
B Interventions gt Antibiotics, Fluids
Nutrition
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Nevada POLST Side One Medical Orders Section
B Interventions gt Limited versus full
treatment
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Nevada POLST Side One Medical Orders Section
C Physician Validation

• To be valid, the Nevada POLST form must, at a
  minimum, be signed and dated by a physician.

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Nevada POLST Side Two Patient Preferences

• Organ Donation
• AD Information Summary of information in
  patients Living Will, Declaration and/or Durable
  Power of Attorney (DPOA)
• Patient/Physician conversation information
• LivingWillLockbox.com information
• General Instructions

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Nevada POLST Side Two Patient
PreferencesSection D Organ Donation

• Verify patients name and date of birth with
  their patient identification bracelet (if the
  patient is in a hospital or similar facility)
• Organ Donation Checking this box does NOT give
  authorization for organ donation. Check the
  patients NV state-issued ID to verify.

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Nevada POLST Side Two Patient
PreferencesSection E Advance Directive Summary

• If the patients Advance Directive (AD) is
  available, this section should be completed.
• If the patient has their AD registered with the
  Nevada Living Will Lockbox, they may have the
  Lockbox ID available.

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Nevada POLST Side Two Patient
PreferencesSection E Advance Directive Summary

• If a patient does not have a Durable Power of
  Attorney for Health Care, then NRS 449.691-
  449.697 defines an order of authority to
  represent the patient (spouse, adult children,
  parents, siblings, other relatives in that order).

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Nevada POLST Side Two Patient
PreferencesSection F Signatures

• The person who prepares Side 2 circles the
  responsible party with whom the physician has
  discussed this document
• An agent is the patient Durable Power of
  Attorney (DPOA) for Healthcare
• The patient, agent, parent (if a minor) or
  guardian signs the POLST form
• A witness signature for anyone preparing the form
  (may be nurse or social worker). Note A
  physician must complete side 1 of the POLST form

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Nevada POLST Side Two Patient
PreferencesSection G Registry

• A POLST form may be registered with the Nevada
• Secretary of States Living Will Lock Box (LWL)
• www.livingwilllockbox.com
• Physicians, physician office staff and hospital
  office staff may be granted access to the LWL
• Sunrise Hospital and several key staff are
  registered with LWL
• POLST and the LWL authorization should be
  completed at the same time with the patient then
  submitted to the LWL to assure state-wide access

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Nevada POLST Law

• A physician or other healthcare provider 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 the
  patients POLST
• The patient, their agent, parent (if a minor) or
  legal guardian over-rides it

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Nevada POLST Law Physician Authority and
Privileges

• Healthcare 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

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Nevada POLST Law Physician Responsibility

• A POLST should be completed for the patient if
• Their life expectance is less than 5 years
• They have a terminal illness
• They request one
• In these instances, the physician shall explain
• The availability of the POLST
• The feature and procedures offered by it
• The differences between the POLST and other
  Advance Directives

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Nevada POLST Law 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
• The patients preferences change
• When a POLST needs to be revised due to wear/tear
  or change of orders/information, the physician
  and patient should
• Write VOID diagonally across both sides of the
  POLST and place in the patients chart
• Complete a new POLST, sign, and date it

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Nevada POLST Law 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, unless it is dated prior
  to the POLST

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Nevada POLST Law Compliance

• Should a physician or other healthcare provider
  be unwilling to comply with the directives of the
  POLST, all reasonable measures shall be taken to
  transfer to a compliant provider or facility
• If a patient is known to be pregnant, so long as
  it is probable that the fetus will develop to the
  point of live birth with the application of
  life-sustaining treatment, life sustaining
  measures shall be attempted

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Nevada POLST Miscellaneous

• Any completed section is valid unless the POLST
  is not signed and dated by a physician
• Blank sections should be presumed to indicate
  full treatment, unless it conflicts with a
  completed section
• The POLST (MOST, POST, MOLST) of another state
  shall be honored in Nevada

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POLST _at_ Sunrise Hospital

• POLST forms are available in Forms Fast
• Upon discharge, the original POLST form is to be
  given to the patient if they are discharged home
  or in the transfer packet, if they are discharged
  to a facility
• A copy of the POLST form remains with the
  patients medical record
• Sunrise Hospital has a Policy Physician Orders
  for Life Sustaining Treatment (POLST)

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References

• Nevada POLST Coalition
• Many thanks to Sally Hardwick, MS with the Nevada
  POLST Coalition
• for creating and editing this presentation.