Download POST Form

POST….
Physician Orders for Scope of Treatment
Respecting Patients’ Wishes
at the End of Life
EMS Train the Trainer
1
An Index Case
Mr. Jan, a 71-year-old male with severe COPD and mild
dementia, was convalescing at a skilled-nursing facility after a
hospital stay for pneumonia. Mr. Jan developed increasing SOB and
decreasing LOC over 24 hours. The nursing facility staff called EMS
who found the patient unresponsive, with a RR of 8 and an O2 sat at
85% on room air. Although Mr. Jan had discussed his desire to forgo
aggressive, life-sustaining measures with his family and nursing
personnel, the nursing facility staff did not document his
preferences, inform the emergency team about them, or mention
his do-not-resuscitate order.
2
After EMS was unable to intubate him at the scene, they inserted an
oral airway, bagged, and transported the patient to the emergency
department (2nd hospital). Mr. Jan remained unresponsive. He was
afebrile, with a systolic BP of 190 mm Hg, P of 105 , RR of 8, and an
O2 sat of 88% despite supplemental oxygen. He had diminished
breath sounds without wheezes, and a chest X-ray showed large
lung volumes without consolidation. Arterial blood gases showed
marked respiratory acidosis. The emergency department physician
wrote, “full code for now, status unclear.” The staff intubated and
sedated Mr. Jan and transferred him to the intensive care unit.
Lynn, et al. Ann Intern Med 2003;138:812-818.
3
What went wrong?
(Could this happen in Roanoke?)
• Advance directives not documented
• DNR order not communicated in
transfer
• Fragmentation in care (2 hospitals)
• Overtreatment against patient’s wishes
• Unnecessary pain and suffering
• System-wide failure to respect pt’s
wishes
– Failure to plan ahead for contingencies
– No system for transfer of plan
4
What is POST?
• A physician order
• Can be completed by any provider but
must be signed by qualified MD or DO
• Complements, but does not replace,
advance directives
• Voluntary use
• Recognized by EMS as a valid DDNR
5
POST is for…
Seriously ill patients*
Terminally ill patients
* chronic, progressive disease/s
6
Purpose of POST
• To provide a mechanism to communicate
patients’ preferences for end-of-life
treatment across treatment settings
• To improve implementation of advance
care planning
7
Expected Outcomes of Using POST
Process
• Improved continuity of care—Form
transferable across treatment settings
• Clearer communication of wishes
• Reduced hospitalization and inappropriate
life-sustaining treatments
– Fewer EMS transports
• More accurate representation of
preferences
• Higher adherence to wishes by medical
professionals.
Living Will* v. POST
•
•
•
•
•
Living Will
For every adult
Requires decisions about
myriad of future treatments
Clear statement of
preferences
Needs to be retrieved
Requires interpretation
•
•
•
•
•
POST
For the seriously ill
Decisions among presented
options
Checking of preferred boxes
Stays with the patient
A physician’s order to be
followed
*Fagerlin & Schneider. Enough: The Failure of the Living Will.
Hastings Center Report 2004;34:30-42.
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Why POST Works…
• MUST accompany patient
• Contains specifics
• Physician’s order—no interpretation
is needed
–POST orders are to be followed
10
Prompt for POST Completion
Would you be surprised
if this patient died
in the next year?
11
Communication across Settings
The health care facility initiating the transfer shall
communicate the existence of the POST form to
the receiving facility prior to the transfer. The
POST form (or copy) shall accompany the person
to the receiving facility and shall remain in effect.
POST Project Policy and Procedure
12
POST Pilot Project
• POST orders legally recognized in
several states, including West
Virginia.
• 8 regions in the state are conducting
POST pilot projects over the next 2
years.
• Plan to make POST a uniform
document recognized throughout
Virginia.
National POLST Paradigm Programs
Endorsed Programs
Developing Programs
No Program (Contacts)
*As of February 2013
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EMS Participants
• List your participating EMS and transport
groups here
EMS Participants
• List your participating EMS and transport
groups here
POST Form
19
Section A: Resuscitation
A
 one only
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
☐ Attempt Resuscitation
☐ Do Not Attempt Resuscitation (DDNR/DNR/No CPR)
A DNR order in this section qualifies as a Durable DNR order. In no case shall any person other than the patient have
authority to revoke a Durable Do Not Resuscitate Order executed upon the request of and with the consent of the
patient himself. § 54.1-2987.1.B
• DNR orders only apply if a person has no pulse and is not
breathing
• Note: This section has 2 choices: Attempt Resuscitation and
Do Not Attempt Resuscitation: Check to see which box is
checked!
• POST Section A recognized as a valid Virginia Other DNR.
• When Do Not Attempt Resuscitation is checked, qualified healthcare
personnel are authorized to honor this order as if it were a Durable DNR
order
• OEMS approval (Michael Berg)
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Section B: Medical Interventions
B
 one only
Comfort
Measures
are always
provided,
regardless
of the level
of care
chosen
MEDICAL INTERVENTIONS: Patient has pulse and / or is breathing.
 Comfort Measures: Treat with dignity and respect. Keep warm and dry. Use medication by any route,
positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual
treatment of airway obstruction as needed for comfort. Transfer to hospital only if comfort needs cannot be met
in current location. Also see “Other Instructions” if indicated below.
 Limited Additional Interventions: Include comfort measures described above. Do not use intubation or
mechanical ventilation. May consider less invasive airway support (e.g., CPAP or BiPAP). Use additional medical
treatment, antibiotics, IV fluids and cardiac monitoring as indicated. (Hospital transfer if indicated. Avoid
intensive care unit.) Also see “Other Instructions” if indicated below.
 Full Interventions: In addition to Comfort Measures above, use intubation, mechanical ventilation, cardioversion
as indicated. Transfer to hospital if indicated. Include intensive care unit. Also see “Other Instructions” if
indicated below.
Other Instructions:
• If in the “terminal” phase, POST and advance directive should be
consistent
• Care plan should always be consistent with POST
• If Comfort Measures are selected consider hospice consultation
21
Levels of Medical Interventions
• Comfort Measures
– Treat with dignity and respect.
– Keep warm and dry.
– Use medication by any route, positioning, wound care and
other measures to relieve pain and suffering.
– Use oxygen, suction and manual treatment of airway
obstruction as needed for comfort.
– Transfer to hospital only if comfort needs cannot be met in
current location. Also see “Other Instructions” if indicated
below.
22
Levels of Medical Interventions
Limited Additional
Interventions
– Include comfort measures.
– Do not use intubation or
mechanical ventilation. May
consider less invasive airway
support (e.g., CPAP or BiPAP).
– Use additional medical
treatment, antibiotics, IV
fluids and cardiac monitoring
as indicated.
– Hospital transfer if indicated.
Avoid intensive care unit. Also
see “Other Instructions” if
indicated below.
Full Interventions
– In addition to Comfort
Measures above
– use intubation, mechanical
ventilation, cardioversion as
indicated.
– Transfer to hospital if
indicated. Include intensive
care unit.
– Also see “Other Instructions”
if indicated below.
23
Section C: Artificial Nutrition
• These orders pertain to a person who cannot take
food by mouth
• Feeding tube for a defined trial period:
• Gives option to determine benefit to patient and/or recovery
from stroke, etc.
24
POST Sections (Other)
Discussed with
Physician Signature and contact info
Patient/Authorized Decision Maker
Authority to sign patient if patient is
incapacitated
Facility of POST form origin
Name and signature of Facilitator
Instructions
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POST Form Shall Always Accompany
Patient/Resident When Transferred or
Discharged!*
On the top of the transfer packet!
* Note: Preferable to transfer with original current copy,
but legible copies are to be honored as though they are
the original.
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“Where is the POST form?”
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At Transfer
• The yellow POST form placed in a red
envelope with a label and placed at top of
transfer documents:
– “POST Order Form---This Form is to Accompany
the Resident Upon Transfer or Discharge; if
resident returns to (name of facility), please
return this form to: (address of facility)
• EMS, hand this envelope to person in charge
of receiving resident/patient transfer
documents.
EMS Role in POST Pilot Project
•
•
•
•
Know what the POST form looks like.
Know location of POST form in transfer records.
Honor DDNR
During transfer, communicate to medical control that
patient has a POST form and the contents of section
A and B.
• At receiving facility, communicate that patient has a
POST form and its location.
EMS Transport Service Roles
• Same as EMS, plus—
• Patient return to residence/facility, ask:
– “Is there a POST Form?”
– “Where is the POST form?”
• Make every effort to ensure the POST form is
transferred with the patient back home or to
the facility.
Take-Home Messages
• POST provides a better means than AD to
identify and respect patients’ wishes
• POST completion will improve end-of-life care
throughout the system
• Use of POST will require communication to
make it work in your community
• “Where’s the POST form?”
31
Questions?