physician’s orders for life-sustaining treatment sharmon figenshaw, arnp, bruce smith, md...
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Physician’s Orders for Life-Sustaining TreatmentSharmon Figenshaw, ARNP, Bruce Smith, MDWashington POLST Task Force Co-Chairs
POLST Update for Professionals
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.
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!
POLST Update for Professionals
What is POLST?
POLST is primarily an outpatient document. When a patient is admitted to a hospital or skilled nursing facility the attending provider should confirm that the POLST orders are still accurate and valid (if possible) and should then transcribe the wishes expressed on the POLST to the facility’s inpatient order set.
POLST orders completed in an inpatient setting should accompany the patient on discharge (with copies to outpatient record systems)
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.
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.
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 some religious circles.
It is important to remember: POLST is always voluntary!
How an Advance Directive and POLST Form Work Together
POLST: In Washington and Nationally
A Brief history of POLST
Pilot project in Spokane led by RENEW project
Adopted statewide in 2000
Shared management by WSMA and DOH
POLST Task Force established to do bi-annual revisions, keeping POLST up-to-date and able to meet the needs of Washington clinicians.
Washington POLST one of 6 original POLST states. Representation on NPPTF.
Oversight of POLST: WEOLC/ WSMA
WEOLC = Washington State End-of-Life Coalition:
A statewide coalition of organizations and individuals who share a common interest in excellent EOL care across the state.
WEOLC steering committee is an interdisciplinary body that establishes priorities and organizes activities, one of which is oversight of the POLST task force.
WSMA, as our parent organization, supports POLST and WEOLC. They maintain the website and house WEOLC/POLST activities
Part of a National Movement: The National POLST Paradigm Task Force
Washington POLST one of 6 original POLST states. Representation on NPPTF.
Setting standards for states with developing, endorsed and mature programs
Giving national attention to common themes and problems, i.e. Catholic concerns about POLST.
Presenting the case of POLST at national government levels.
POLST: Doing it Better
https://www.google.com/search?q=youtube+polst+doing+it+better&rlz=1C5CHFA_enUS606US606&oq=youtube+polst+doing+it+better&aqs=chrome..69i57.7719j0j4&sourceid=chrome&es_sm=91&ie=UTF-8
Oregon POLST team created video toStrengthen understandingDispel mythsRepresent multi-state useEncourage Adoption
Hyperlink to video below
POLST Updates for Washington
Current Challenges/Identified Needs
Ruling on home and facility caregivers honoring POLST
Dispelling myths regarding legality, morality and criteria for having a POLST
Ongoing revisions: review recent changes, proposed changes, We want to have time for your input.
Updated training for EMS and providers
Successes 2014-2015: Caregiver Training
Identified Need: DSHS had issued a statement that caregivers must start CPR regardless of POLST or other indications of patient wishes
Background: Caregivers received no training on POLST and therefore could not be expected to honor it.
Successes 2014-2015: Caregiver Training
Goal: Address education for caregiversGrant awarded:
$5000 from The Retirement Fund through NPPTF
Project Outline:The video/education project garnered the support of
a large group of stakeholdersVideo came first: script reviewed extensivelyTeam of education experts in long-term care and
other care-giving agencies formed work group to design a curriculum based on the video.
Video Launched: 2015http://wsma.org/wcm/For_Patients/End_of_Life/POLST/For_Providers/wcm/Patients/POLST.aspxhkey=79b85594-44ef-4821-b299-648251959669
Proposed Training release: Fall/Winter 2015-16
NCQAC Advisory Opinion
The nursing commission advisory opinion on POLST was issued this summer, after sessions which included input from the POLST lobbyist, POLST task force and DSHS representatives.
The Nursing Commission opinion confirms that the scope of practice of nurse’s aides includes honoring Section A of the POLST form
Myths about POLST: POLST is “illegal”
FACT: POLST is a MEDICAL ORDER!
The legal stance for POLST is the same as other medical orders. Providers have always worked with patients to determine their “CODE” status.
The shared decision-making process of the POLST is liken to the informed consent process.
Having the patient/surrogate sign the form uniquely signifies the patient-provider communication for this important order
MYTH: POLST is “immoral/unethical”
FACT: POLST and advance care planning are consistent with Catholic ethical teaching as described in the Ethical and Religious Directives for Catholic Health Care (ERDs)Specifically:• ERD 23: POLST is a process intended to respect and protect the inherent
human dignity of the patient• ERDs 26 and 59: POLST facilitates the process of free and informed
consent that is required for medical treatments and procedures• ERD 28: Using POLST is one way to assist each person or their
representative to have access to medical information and counseling to be able to form his or her conscience
• ERDs 33, 56, and 57: POLST provides an opportunity to evaluate whether specific medical treatments offer reasonable hope of benefit without entailing excessive burdens
• ERD 60: POLST does NOT present an option for physician assisted suicide or euthanasia
From: Dr. Susan Nelson. Incorporating the Faith Perspective. Ppt. February 2015.
Statewide Catholic hospital systems use POLST
Locally, Providence Health System, Franciscan Health System and PeaceHealth are all supportive of POLST
Providence is developing an electronic“e-POLST”, expected to pilot in Oregon
Myth: People will be denied care unless they agree to sign a POLST
FACT: POLST is ALWAYS Voluntary!
Like all forms of patient directives, POLST cannot be required as a condition of admission to nursing home or any other facility.Facilities and providers ARE allowed to ignore patient directives if following them is morally objectionable (Natural Death Act). There is no law REQUIRING facilities to honor Advance Directives or POLST
Question: As a medical order, does POLST carry more imperative to be honored?
The Myth of Immunity
The DOH statute covering EMTs with “immunity” has become a bar that all providers now hope for.
But… realize, as medical providers, we do not have “immunity” for all the medical care we give; we must use good medical judgment that is defensible.
Not having immunity is NOT a reason to NOT respect our patient’s wishes.
POLST Revisions 2011
2011:Moved Antibiotics and tube feeding preferences to back of form
Rationale: Keep front of form focused on truly emergent care decisions. Decisions
about antibiotics and tube feedings can take place over hours or days, not minutes. Front of form is for EMS, back of form to guide ongoing care.
Moved Medical Condition/Patient Goals Section up on page Increase focus on PATIENT and their goalsProvides context for plan. ENCOURAGE USE!!
Expanded Introduction paragraph/ Revisions to Directions on backMore clarity regarding use
Expanded language in Signature sectionSuggestions of legal representatives to POLST TF.Provides assurance/reminder to medical team about intentions
Added SSN last 4May provide for use in EMRs
POLST Revisions 2014
2014:Changed title of Section D from “Additional Patient Preferences (Optional)” to
“Non-Emergency Medical Treatment Preferences”:More clarity about purpose of this section.
Added Patient/surrogate signature to treatment preferences on backReinforce shared decision-making
Revised Introduction paragraph/ Revised Directions on backStressed that POLST is Voluntary!Added “ usually for persons with advanced illness or frailty”
Revision in Signature sectionAdded RCW reference for surrogate decision-makers.
Added “See back of form for non-emergency preferences”Removed Living Will Registry box on frontAdded website to bottom frontKept Medical Condition/Patient Goals Section up on page
Increase focus on PATIENT and their goalsProvides context for plan. ENCOURAGE USE!!
Proposed POLST Revisions 2016
2014:Continue to review position and content of Section D from “Additional Patient
Preferences (Optional)” to “Non-Emergency Medical Treatment Preferences”:More clarity about purpose of this section.
Consider adding Patient identification to back pageEncourage faxing of both sides
Revised Directions on backRemove “usually for persons with advanced illness or frailty”
Change Titles of Section A and B to focus on Patient conditionE.G.“Person Has No Pulse/ Is Not Breathing” would come first
Add: “No Exceptions” box to Section ANursing Commission advisory opinion includes this suggestion
Reverse order of choices in Section BThis flows more naturally with how care options are usually presented,
most aggressive first, then move to comfort.Seen as injected “bias” toward comfort if this is first
Consider how to make Medical Condition/Patient Goals Section more useful Increase focus on PATIENT and their goalsProvides context for plan. ENCOURAGE USE!!
Provider and EMS Education
• New EMS director on POLST task force working to update EMS training
• New curriculum being developed based on California’s well supported work
• Possible avenues A “train-the-trainer” program in the next year. Partnering with local organizations to support
in-house education• Email Sharmon with your interest/ideas
Sustainability
• Goal of paid administration/program manager
• Grants• Member support• Your ideas?
• We want to maintain a strong POLST program to ensure Washington residents receive wanted and appropriate care!
POLST Needs Your SUPPORT!
• Talk about POLST• Make sure POLST is part of the
conversation in your organization/community about Advance Directives and honoring patient choices
• Let us know what questions/issues you have or are aware of regarding [email protected]
Contact Information
Washington POLST Task Force Co-Chairs: Sharmon Figenshaw ARNP
[email protected] [email protected]
Bruce Smith, MD, FACP [email protected]
For more information Graham Short: [email protected]
Immense Gratitude
• The POLST program, and these presenters, want to acknowledge with deep gratitude:
• Jim Shaw and Sally Dent for their early and sustaining work for the POLST in Washington, including the development of these slides
• Stuart and Lu Farber, whose mentorship lives in this work, and the work of so much patient goal-centered training in Washington and beyond.
In Memory of:
• Stu Farber (1947- Feb 26, 2015) a treasured mentor, friend and human being
whose vision lives through the work that survives him
“Late Fragment”
And did you get whatyou wanted from this life, even so?I did.And what did you want?To call myself beloved, to feel myselfbeloved on the earth.
- Raymond Carver
Any Questions?
Thank You!
POLST Resources
POLST Resources
National POLST Paradigm www.polst.org
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, [email protected].
Washington POLST Task Force Co-Chairs: Bruce Smith, MD: [email protected]. Sharmon Figenshaw, ARNP: [email protected].
Link to videos
• Caregiver Video• http://wsma.org/wcm/For_Patients/End_of_Life/POLST/
For_Providers/wcm/Patients/POLST.aspx?hkey=79b85594-44ef-4821-b299-648251959669
• https://trustilp.com/crm/pages/project_view.php?id=sf77n14a05
• Oregon Provider video: “POLST: Doing it better”• https://www.google.com/search?
q=youtube+polst+doing+it+better&rlz=1C5CHFA_enUS606US606&oq=youtube+polst+doing+it+better&aqs=chrome..69i57.7719j0j4&sourceid=chrome&es_sm=91&ie=UTF-8