Physician’s Orders for Life-Sustaining Treatment
Sharmon Figenshaw, ARNP, Bruce Smith, MD
Washington POLST Task Force Co-C...
POLST Update for Professionals
POLST Update for Professionals
What is POLST?
 “Portable” medical orders for treatment decisions,
including end-of-life c...
POLST Update for Professionals
What is POLST?
 Patient & provider shared decision-making model: Brings together
patient g...
POLST Update for Professionals
Philosophy of POLST
 Individuals have the right to make their own health care
decisions. T...
POLST Update for Professionals
POLST: Who Should Have One?
 Who should have POLST form:
 Persons with advanced or chroni...
POLST Update for Professionals
POLST: Who Could Have One?
 Anyone choosing:
 To limit medical treatments
 Do Not Resusc...
How an Advance Directive and POLST Form Work Together
POLST Update for Professionals
Establish Goals of Care
 Shared decision-making based on the patient’s values
and goals in...
How POLST
Works
The POLST Form (Front)
Medical Condition/Patient Goals
 A simple description of medical condition
 A direct statement of...
The POLST Form (Front)
Part A: Code Status
 Instructions regarding Cardiopulmonary Resuscitation
(CPR): Includes EMS
Pati...
The POLST Form (Front)
Part B: Medical Interventions
Patient/resident has pulse and/respirations
 Comfort Measures Only:
...
The POLST Form (Front)
Part B: Medical Interventions
Patient/resident has pulse and/respirations
 Limited Additional Inte...
The POLST Form (Front)
Part B: Medical Interventions
Patient/resident has pulse and/respirations
 Full Treatment and Inte...
The POLST Form (Front)
Signatures
 Statement of Intent:
 The signatures below verify that these orders are consistent wi...
The POLST Form (Front)
Signatures
 Patient signature always preferred.
 If patient present but surrogate signing, note p...
The POLST Form (Front)
Signatures
 Physician (MD, DO) or Advanced Care Practitioner
(ARNP or PA-C) must sign.
 Verbal or...
The POLST Form (Back)
Part D
 Additional Patient Preferences (Optional)
 This includes antibiotics and nutrition therapy...
The POLST Form (Back)
Part D: Antibiotic Therapy
 Antibiotics for infection: whatever the choice, notify
physician of new...
The POLST Form (Back)
Part D: Medically Assisted Nutrition
 Artificially Administered Nutrition by parenteral or enteral
...
The POLST Form (Back)
Directions for Health Care Professionals
 Completing POLST
 Must be completed by health care profe...
The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST
 Any incomplete section of POLST implies ful...
The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST: SECTION A
 Patient has no pulse/no respirat...
The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST: SECTION B
 When comfort cannot be achieved ...
The POLST Form (Back)
Directions for Health Care Professionals
 Using POLST: SECTION D
 Oral food and fluids must be off...
The POLST Form (Back)
Directions for Health Care Professionals
 Reviewing POLST: Review when:
1) The person is transferre...
POLST
Resources
POLST Resources
Washington State Medical Association
 Provides POLST forms and information.
 Order at www.wsma.org/pols...
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POLST Skills Development - Sharmon Figenshaw and Bruce Smith

POLST Skills Development – Sharmon Figenshaw, ARNP, RN; and Bruce Smith, MD Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College
Published on: Mar 4, 2016
Published in: Healthcare      
Source: www.slideshare.net


Transcripts - POLST Skills Development - Sharmon Figenshaw and Bruce Smith

  • 1. Physician’s Orders for Life-Sustaining Treatment Sharmon Figenshaw, ARNP, Bruce Smith, MD Washington POLST Task Force Co-Chairs
  • 2. POLST Update for Professionals
  • 3. POLST Update for Professionals What is POLST?  “Portable” medical orders for treatment decisions, including end-of-life care; conforms to medical standards of care.  Defines patient preference for health care options based on current physical/medical condition.  POLST can translate an advance directive into physician’s orders or reflect change in preferences based on change in medical condition.
  • 4. POLST Update for Professionals What is POLST?  Patient & provider shared decision-making model: Brings together patient goals/values and practitioner-guided consideration of current medical condition.  Translates patient wishes into orders that can be followed by EMS (and hopefully other bedside providers).  Options include range of care from full code/full measures to DNR/comfort.  Power and portability REMEMBER: Conversations for goals of care come first!
  • 5. POLST Update for Professionals Philosophy of POLST  Individuals have the right to make their own health care decisions. These rights include:  Making decisions about accepting or refusing life-sustaining treatment.  Having their decisions honored by health care providers.  Comfort care while having wishes honored.  POLST allows people to “opt out” of the default “full code” of standard emergency/medical care.
  • 6. POLST Update for Professionals POLST: Who Should Have One?  Who should have POLST form:  Persons with advanced or chronic illness, or frailty.  Condition for which resuscitation is inappropriate including when survival is unlikely.  Anyone who “you wouldn’t be surprised” if they were to die within the next year.  Good clinical documentation  Especially when surrogates are decision makers.
  • 7. POLST Update for Professionals POLST: Who Could Have One?  Anyone choosing:  To limit medical treatments  Do Not Resuscitate/No Code/Allow Natural Death  Advanced age >80 years old (without mental instability) This covers our healthy seniors who want to make sure that they do not receive unwanted CPR or burdensome hospitalizations.* *There is some debate about this in religious circles. It is important to remember: POLST is always voluntary!
  • 8. How an Advance Directive and POLST Form Work Together
  • 9. POLST Update for Professionals Establish Goals of Care  Shared decision-making based on the patient’s values and goals in light of their current medical condition:  “What do you understand about your condition?”  Informed consent: Patients need information about risks and benefits of life-saving measures!  “What are you hoping for? What might you be afraid of?”  Initiate in the hospital by the time of discharge if not already done by primary care provider.  “How would you like to live your life?”
  • 10. How POLST Works
  • 11. The POLST Form (Front) Medical Condition/Patient Goals  A simple description of medical condition  A direct statement of the patient/family’s goals in their own words is one of the most important pieces of information we can gather.  This may guide care decisions when nothing else can. Agency Info/Sticker  Write in, or place sticker here for an agency.
  • 12. The POLST Form (Front) Part A: Code Status  Instructions regarding Cardiopulmonary Resuscitation (CPR): Includes EMS Patient has no pulse and is not breathing  CPR/Resuscitate  Do Not Attempt Resuscitation (DNAR) / Allow Natural Death (AND)  Comfort measures will always be provided
  • 13. The POLST Form (Front) Part B: Medical Interventions Patient/resident has pulse and/respirations  Comfort Measures Only:  Medication by any route, positioning, wound care.  Other measures to relieve pain and suffering.  Use oxygen, oral suction and manual treatment of airway obstruction as needed for comfort.  Patient prefers no transfer: EMS contact medical control to determine if transport indicated.
  • 14. The POLST Form (Front) Part B: Medical Interventions Patient/resident has pulse and/respirations  Limited Additional Interventions:  Includes care listed above in comfort care.  Medical treatment, IV fluids and cardiac monitor as indicated. Do not use intubation or mechanical ventilation.  Transfer if indicated, avoid ICU if possible.
  • 15. The POLST Form (Front) Part B: Medical Interventions Patient/resident has pulse and/respirations  Full Treatment and Interventions:  All care in both sections above plus intubation and cardioversion.  Transfer to hospital if indicated. Includes intensive care.  Additional Orders: (e.g. dialysis, etc.)  Use this section to state specific therapies, like dialysis and blood transfusions and the goals or time limits for these.
  • 16. The POLST Form (Front) Signatures  Statement of Intent:  The signatures below verify that these orders are consistent with the patient’s medical condition, known preferences and best known information. If signed by a surrogate, the patient must be decisionally incapacitated and the person signing is the legal surrogate.  Indicate who was involved in decision-making:  Patient  Parent of minor  Guardian with Health Care Authority  Spouse (or Domestic Partner. Indicate this)  Health Care Agent (DPOAHC)
  • 17. The POLST Form (Front) Signatures  Patient signature always preferred.  If patient present but surrogate signing, note presence and agreement of patient.  Surrogates for signing (Washington state):  Guardian  DPOA  Spouse/Registered domestic partner  Adult children  Parent  Adult sibling  Beyond that, there is no regulatory guidance. Consult ethics. Use team-decision making model with any family available.
  • 18. The POLST Form (Front) Signatures  Physician (MD, DO) or Advanced Care Practitioner (ARNP or PA-C) must sign.  Verbal orders are acceptable with follow-up signature by physician, ARNP or PA in accordance with existing policies.  Signatures attest to the informed consent process having occurred.  Different health care settings designate/train different personnel for this purpose.
  • 19. The POLST Form (Back) Part D  Additional Patient Preferences (Optional)  This includes antibiotics and nutrition therapy options.  Formerly Parts C & D on front of form.  Meant to guide therapies in non-emergent situations.  Patient and provider signatures testify that conversation has taken place.
  • 20. The POLST Form (Back) Part D: Antibiotic Therapy  Antibiotics for infection: whatever the choice, notify physician of new infection  No antibiotics: use other measures to relieve symptoms.  Determine use or limitation of antibiotics when infection occurs, with comfort as goal.  Use antibiotics with the goal of prolonging life.
  • 21. The POLST Form (Back) Part D: Medically Assisted Nutrition  Artificially Administered Nutrition by parenteral or enteral route  No artificial nutrition by tube.  Trial period of artificial nutrition by tube. (Goal: Write in how long, till what event or goal is reached.)  Long-term artificial nutrition by tube.  Always offer food and liquids by mouth if feasible.  Additional orders:  Name specific goals of patient.
  • 22. The POLST Form (Back) Directions for Health Care Professionals  Completing POLST  Must be completed by health care professional.  Members of the health care team, RN, MSW, with proper training are well- positioned to have the appropriate conversations.  Should reflect the person’s current preferences and medical indications. Encourage completion of an advance directive. Advance directive should indicate congruent choices.  POLST must be signed by a physician (MD or DO)/ARNP/PA-C to be valid. Verbal orders are acceptable with follow-up signature per facility policy (see sample policies available at awphd.org or wsha.org).
  • 23. The POLST Form (Back) Directions for Health Care Professionals  Using POLST  Any incomplete section of POLST implies full treatment for that section.  This POLST is effective across all settings including hospitals until replaced by new physician’s orders.  The health care professional should inquire about other advance directives. In the event of a conflict, the most recently completed POLST form takes precedence.
  • 24. The POLST Form (Back) Directions for Health Care Professionals  Using POLST: SECTION A  Patient has no pulse/no respirations  No defibrillator (internal or external) should be used on a person who has chosen “Do Not Attempt Resuscitation.”
  • 25. The POLST Form (Back) Directions for Health Care Professionals  Using POLST: SECTION B  When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).  An IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”  Treatment of dehydration with IV fluids may prolong life. A person who desires IV fluids should indicate “Limited Additional Interventions” (or “Full Treatment” if more aggressive care desired).
  • 26. The POLST Form (Back) Directions for Health Care Professionals  Using POLST: SECTION D  Oral food and fluids must be offered if feasible.
  • 27. The POLST Form (Back) Directions for Health Care Professionals  Reviewing POLST: Review when: 1) The person is transferred from one care setting or care level to another, or 2) There is a substantial change in the person’s health status, or 3) The person’s treatment preferences change.  A person with capacity, or the surrogate of a person without capacity, can void the form and request alternative treatment.  FORM CAN BE VOIDED; changes require new POLST. (Desire for CPR and full treatment do not require POLST.)
  • 28. POLST Resources
  • 29. POLST Resources Washington State Medical Association  Provides POLST forms and information.  Order at www.wsma.org/polst or call (206) 441-9762.  For general POLST information contact: Graham Short, WSMA associate director of communications, (206) 329-6851, gfs@wsma.org. Washington POLST Task Force Co-Chairs:  Bruce Smith, MD: bruce.smith@regence.com.  Sharmon Figenshaw, ARNP: shar@dslnorthwest.net.

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