POLST: How Can We Do Better in Long

Term Care?

Introducing: Understanding POLST

For Information Contact:Oregon POLST ProgramPhone: 503-494-3965orpolst@ohsu.edu

PresenterPresentation NotesShow Understanding POLST

Introducing: POLST: How Can We Do Better?

For Information Contact:Oregon POLST ProgramPhone: 503-494-3965orpolst@ohsu.edu

PresenterPresentation NotesShow new film, POLST: Doing it Better

Objectives:

1. Learn about the implication of Alert on POLST use

2. Understand which patients are POLST appropriate

3. Best practices for POLST in Long Term Care Facilities

Provider Alert

Nursing Facility Providers IM-15-06-NF

Date: February 13, 2015 From: Nursing Facility Licensing Unit Subject: CPR, POLST and Advance Directives

Summary: The purposes of this Alert include:

Summary of recent CMS communication regarding provision of CPR in Nursing Facilities (NFs). Overview of Physician Orders for Life Sustaining Treatment (POLST), Advance Directives and related NF Compliance requirements.

Department of Human Services Office of Licensing and Regulatory Oversight

PO Box 14530, Salem, OR 97309 3406 Cherry Ave NE, Salem, OR 97303

PresenterPresentation NotesNursing Facility Alert released in response to CMS communications requiring CPR if patient doesnt have a code status or POLST orders requesting otherwise

Department of Human Services

Office of Licensing and Regulatory Oversight

PO Box 14530, Salem, OR 97309

3406 Cherry Ave NE, Salem, OR 97303

Phone: (503) 373-2227

Fax (503) 378-8966

Provider Alert

Nursing Facility Providers IM-15-06-NF

Date: February 13, 2015

From: Nursing Facility Licensing Unit Subject: CPR, POLST and Advance Directives

Summary: The purposes of this Alert include:

Summary of recent CMS communication regarding provision of CPR in Nursing Facilities (NFs).

Overview of Physician Orders for Life Sustaining Treatment (POLST), Advance Directives and related NF Compliance requirements.

CMS S&C 14-01-NH, originally released October 18, 2013 has been revised January 23, 2015:

CMS S&C 14-01-NH:

o For residents who do not have a DNR order or a POLST form with a DNR order, facility staff must provide basic life support, including the initiation of CPR, prior to the arrival of emergency medical services (EMS).

CMS S&C 14-01-NH:

o For residents who have a Do Not Resuscitate (DNR) order or a POLST form with a DNR order, CPR is not initiated, in accordance with the DNR order.

POLST: KEY PIONTS

Facilities should never require a POLST Not everyone needs a POLST Without POLST or code status orders a patient will

receive CPR POLST can be changed and a new form completed

PresenterPresentation NotesFacilities should never require POLST (should never be included in admission packets for residents to complete on their own). POLST form requires the signature of an MD/DO/PA/NP, and isnt valid without it. Form includes medically complex language that lay people dont fully understand. POLST forms should be filled out on patients who desire a POLST and/or are POLST appropriate. They should NOT be filled out on all patients as way of documenting code status. If the patient does not want a POLST or is not POLST appropriate, the code status should be filled out on a facility code order. POLST forms are sent to the registry from the facility and live on there and should be sent only on POLST appropriate patients. Not everyone needs a POLST. Healthy adults over the age 18 should have an Advance Directive. POLST is for specific population: seriously ill or frail with one year of life left to live.CMS mandate requiring all patients receive CPR unless they have orders to the contrary. This has always been true, but the communication has resulted in over use of POLSTPOLST forms can and should be changed as a patients health status changes or their wishes change. New form should be submitted to the Registry.

What is the impact of advance directives?

PresenterPresentation Notes2 important thing they do:1. they lift an emotional burden. We have formally interviewed people 6 months after death of loved one, measured stress levels, people rated the stress (waking up at 2 am not knowing what loved one would want), family members have a lot of self doubt. Appointing a surrogate ahead of time prevents situations where family members have to make these decisions on their own.2. they appoint a legally authorized surrogate, there can be great agreement/disagreement. Default surrogate isnt always the right person. They allow patients to outline their values in health care

How Advance Directives and POLST Work Together

Adapted with permission from California POLST Education Program January 2010 Coalition for Compassionate Care of California

Age 18

Complete an Advance Directive

Update Advance Directive Periodically

Diagnosed with Advanced Illness or Frailty(at any age)

Complete a POLST Form

Change in health status

May Complete a new POLST Form

Treatment Wishes Honored

PresenterPresentation NotesThe AD is for anyone over 18 and cognitively intact. It periodically needs to be updated. As patients becomes more advanced in chronic illness/frail, the POLST orders are appropriate. POLST doesnt have age restriction. As peoples health status changes, they should update the POLST orders as their wishes for treatment change. It is not unusual for a patient to have multiple POLST forms during the course of a chronic illness.

POLST -Advance Directive

POLSTPhysician Order for Life-Sustaining Treatment

Advance DirectiveOregons Legal Form

Is a Medical Order Is a Legal Document

Immediately takes effect. EMS can follow orders

Needs interpretation to be effective. EMS cannot follow (because not medical orders)

No age limit Signed by MD, NP, or PA in

Oregon

All competent adults over 18 Signed by the resident

PresenterPresentation NotesKey differences- look at handout for more information.

3 I want to reiterate.

Traditional code status orders serve some residents

In case of cardiac arrest:

_____ Resuscitate_____ Do Not Resuscitate

_______________________Physician Signature

PresenterPresentation Notes-for facilities that require medical orders, but patient is too healthy for a POLST form a code status document is a good alternative

2014 Oregon POLST Form

PresenterPresentation NotesOregon changes its POLST Form with new information/technology about every 3 years. Above is the most recent form released in October 2014. All prior versions remain valid. We ask facilities to throw away blank versions and replace with the new version because we are making improvements with each revision. In the 2014 version, there are several important changes: 1) documentation of the Discussion is required 2) All other states but one require the signature of the patient. In Oregon we do not require the signature, but now we are recommending. 3) the health care provider now needs to attest to having the conversation and with whom and a signature verifies personal knowledge that the information is correct.

This has several implications for LTCFor incapacitated patients, it needs to be clear that the discussion has occurred with the appropriate legal decision makernot just the person in the room. The name of the person the POLST was discussed with has to be documentedHealth Care providers now need to attest that the information is correct. They cannot simply sign a form filled out by someone in the facility without verifying the information is correct.

Who should have a POLST form?

PresenterPresentation NotesOne of the most common questions is who should have a POLST form? In Oregon, over 200,000 POLST Forms have been submitted to Registry in the 5 years it has been in operation. One of the challenges is that POLST is being offered to patients who are too healthy to have one. This is a problem because they are thinking about future not present health wishes. The POLST is for treatment wishes to be followed by EMS tonight if found down. Meaning that a 65 year old with no illness should have an advance directive, on a POLST form, this person would mark yes to everything. Yes to everything means that person shouldnt have a POLST form because that is the treatment they would receive from EMS without a POLST form. Offer POLST forms to persons who qualify as I wouldnt be surprised in the coming year due to advanced frailty (likewise, I wouldnt be surprised if they lived another 2 years), clearly they are so frail that CPR would likely be unsuccessful.There are some patients who are absolutely certain they do not want to go to the ICU and they want a POLST form (even though they might not be seriously ill or frail). This person after complete discussion with the Health Care provider should have a POLST. Many patients in SNF for orthopedic procedures for example, do not meet this criteria and should not have a POLST

POLST IS ENTIRELY VOLUNTARY

No one has to complete a POLST

Choice to have or limit treatments

Revoke or change at anytime

Comfort measures are always provided

While facilities routinely record Code Status, they cannot require that patients have a POLST form as a condition of care.

State and federal regulations do not require POLST forms for every resident of a long term care facility.

PresenterPresentation NotesTh