The Georgia POLST

The Georgia POLST

The Role of POLST in Advance Care Planning Richard W. Cohen MD Financial Disclosure This presenter has no financial interests or relationships to disclose 2 Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life

The IOM committee believes a person-centered, familyoriented approach that honors individual preferences and promotes quality of life through the end of life should be a national priority. ica-Improving-Quality-andSEPTEMBER 2014 Honoring-Individual-Preferences-Near-the-End-of -Life.aspx 3

END-OF-LIFE DEMOGRAPHICS IN THE U.S. The majority of deaths occur in elderly adults Seriously ill patients spend most of their final months at home, but most deaths occur in the hospital or nursing home Location of death varies regionally: Portland: 35% in hospitals New York City: >70% in hospitals 4 QUALITY OF END-OF-LIFE IN THE U.S. Typical deaths are:

slow, associated with chronic disease and in persons with multiple problems marked by dependency and care needs 5 QUALITY OF END-OF-LIFE IN THE U.S. Quality of life during the dying process is often poor because of: inadequate treatment of distress fragmented care strains on family, support system Difficult decisions about use of life-prolonging

treatments are commonly necessary 6 One conversation can make all the difference 70% of people say they prefer to die at home yet 70% die in a hospital, nursing home, or long-termcare facility (Centers for Disease Control, 2005) 82% of people say its important to put their wishes in writing ; 23% have actually done it (Survey of Californians by the California HealthCare Foundation, 2012) 80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care;

7% report having had an end-of-life conversation with their doctor (Survey of Californians by the California HealthCare Foundation, 2012) 7 How Physicians want to die p:// 8 End-of-Life Principles

End-Of-Life Care Is About: Compassion at the bedside Providing comfort Honoring patients preferences Advance Care Planning "Advance Care Planning Is Not An Event, It's A Process." - Susan Tolle, Director of the Center for Ethics in Health Care at Oregon Health & Science University 10

10 Advance Care Planning When Should Advance Care Planning Happen? While individuals are still actively able to participate in the conversation prior to a crisis Planning is important! It wasnt raining when Noah started the ark.

~ Richard Cushing Advance Care Planning Talk with the patient Have the surrogate (proxy) there Try to discern: If the patient understands his/her situation What is most important to him/her now If the patient understands his/her choices Discussion of trade-offs and goals of care Use compassionate honesty Gold Standard

Discussing and following a patients preferences for end-of-life care should be as routine as asking about and responding to a patients allergies to medicines Right to Refuse Medical Treatments In Georgia, a competent adult has the right to refuse any unwanted medical treatment for any reason Right to refuse medical treatments includes life support and other lifesustaining treatments

The right to refuse or terminate treatments may be exercised by family members or loved ones Algorithm to Determine Persons Wishes Does the person have capacity to make decisions? Do they have an Advance Directive? Result NO

Does it specify Healthcare proxy? Yes Yes Mediate HCP NO Is the HCP

decisions c/w the Advance Directive? Yes Follow Advance Directive Yes Ask Person NO

Yes Does it specify decisions? NO Follow Healthcare proxy NO NO

Can they explain consequences of their decision? Seek informal HCP Yes Follow Persons Decisions 16

History It is a National movement Advance Directive POLST The Conversation It is a State movement Georgia Health Decision Georgia POLST Collaborative Tools For Advance Care Planning These are now all part of the Ga. 2007 AD law Living Will

Specifies what kind of treatment should be given if you cannot speak for yourself Only effective when you cannot make decisions Durable Power of Attorney for Health Care Allows an agent to be appointed to carry out health care decisions when you cannot Guardianship Allows you to nominate someone to be appointed as

Guardian if a court rules that a guardian is necessary Georgia Advance Directive for Health Care In 2007, Georgia Law combined all three advance care planning tools into one document: Naming a health care agent Stating treatment preferences Nominating a guardian (if a court rules that a guardian is necessary) Also includes: Authorizing organ donation, autopsy, burial Legal with:

Patient signature & 2 witnesses POLST Physician Orders for Life Sustaining Treatment Medical order completed by a health care provider Requires signatures by the patient or patients authorized representative AND a physician Activates a patients Advance directive Mechanism to communicate a patients wishes for their care at the end of their life

Designed to travel with patient from one care setting to another Must be honored by all health care professionals Physician Order for Life Sustaining Treatment (POLST) POLST in action: Oregon deaths 2011-2012; 17,902 (30.9%) had a POLST form in the registry Comfort measure only (CMO) 11,836 (66.1%) avoiding hospitalization unless comfort cannot be achieved in the current setting Only 6.4% of participants with POLST CMO orders died in the hospital

Full treatment requested - 44.2% died in the hospital ~ J Am Geriatr Soc 62:12461251, 2014. 1/26/20 21 Who Should Have a POLST? Anyone who wants their end-of-life decisions honored Anyone choosing Allow Natural Death or DNR Anyone choosing to limit or not limit medical

interventions Anyone residing in a long term care facility Anyone who might die or lose decisionmaking capacity within the next year Difference Between Advance Directives and POLST Advance Directive POLST For anyone over 18 For seriously ill/frail at any age

Completed by an individual Completed by a physician and patient or authorized patient representative General instructions for future treatment Specific orders for current treatment Signed by individual and two witnesses (neither an attorney nor

notary is needed in GA) Signed by physician and patient or authorized patient representative Georgia Legal Foundations GA Advance Directive Ga. AD Law - 2007 HB 24 Ga. Dept. Of Human Resources (2007 HB 24 Rules And Regulations) Ga. Code 31-39 DNR/AND & Cardiopulmonary Resuscitation Laws GA Physician Order For Life Sustaining Treatment

(POLST) Ga. DPH, POLST Form, 2012 SB 109 2015 SB109 A Legally Sufficient Order In All Settings Valid Consent Unless Revoked From Another State If substantially similar & with the same signatures A Copy

SB109 Portable Across Care Settings Review of form recommended as care transitions Immunity For All, including guardian actions Protections for treating pain Except if violates Code Section 16-5-5 Assisted Suicide SB109 Equates Terms DNR=AND etc. All conflicting laws or parts are repealed

Most recent document is the valid one Georgia POLST Form Developed by the Georgia Department of Public Health in

2012 pursuant to Official Code of Georgia Section 29-418(l) Available at Use

and compliance with POLST form provides immunity to any person acting good faith (2015) in

Georgia POLST Form Five Sections Cardiopulmonary Resuscitation (CPR) Medical Interventions Antibiotics Artificially Administered Nutrition Signatures 1/26/20

29 Signatures Two Required Patient & Physician OR Authorized Person / Healthcare Advocate & Physician OR Two physicians Remember Physician must be on the staff of the institution honoring the POLST

POLST Conversation POLST is not just a check-box form The POLST conversation provides context for patients/families to: Make informed decisions Identify goals of treatment A patient or their Health Care Agent can request alternative treatment or revoke a POLST at any time POLST Implementation/Use in Hospital Setting Medicare Conditions of Participation: Hospital orders may only

be written by MD with staff privileges; this does not mean a POLST signed by a non-privileged physician should be ignored. POLST Process when Patient Arrives at Hospital with POLST signed by non-privileged physician: Physician should review the document(s) Either co-sign the POLST or Rewrite orders into hospital system Hospital policies should be written to govern this process David W. Eddinger, RN, MPH Captain US Public Health Service, Retired Technical Director Hospital Survey and Certification CMS/CCSQ/Survey & Certification Group/Division of Acute Care Services

Identify or determine: Health Care Admission to Long-Term Care (LTC) Facility Advocates name Patients medical state Code status based on:

Patients wishes and/ or When, in the judgment of a physician, Either: A

patient is in a terminal condition A patient is in a permanent

state of unconsciousness In medical judgment CPR would be medically inappropriate

O.C.G.A. 31-39-4 (2010) Health Care Team Responsibilities in ALL Healthcare Settings To follow the patients known preferences To honor the patients Advance Directive and POLST without regard to personal views If unable to honor preferences, facilitate the transfer of patients care 1/26/20 34

Healthcare Agent / Authorized Person Must be named in either Advance Directive POA Responsibilities: To follow the patients known preferences To honor the patients Advance Directive and POLST To act in the best interest of the patient 35

My Vision 1/26/20 36 Georgia POLST Collaborative 40+ Statewide Organizations Part of a national movement to promote POLST Endorsed by the National POLST Paradigm Taskforce Vision: All Georgians will have their

health care preferences known and honored 1/26/20 39 Georgia POLST Collaborative (contd) Mission: To improve health care at the end-of-life through Promoting the utilization of the Physician Orders for Life Sustaining Treatment form by health care

professionals and institutions across the state Educating Georgians about advance care planning and the role of POLST in having their wishes honored Getting it Right Honor all patients wishes Encourage all patients to have an Advance Care Plan Utilize POLST when patient condition applies

Apply reasonable medical judgment Additional Resources Critical Conditions Guide http:// georgiahealthdecision Prepare For Your Care Step Step

Step Step Step 1: Choose a Medical Decision Maker 2: Decide What Matters Most in Life 3: Choose Flexibility for Your Decision Maker 4: Tell Others About Your Wishes 5: Ask Doctors the Right Questions http://prepareforyourcare.o g /

Conversation Project Veteran Boston journalist Ellen Goodman Launched in August 2012 Backing from the Institute for Healthcare Improvement Conversation Project Goodman, who launched her project after a difficult experience caring for her own dying

mother, says, "What we really need is to change the cultural norm from not talking about it to talking about it." Lets Have Dinner and Talk About Death Michael Hebb TED Talk Death Over Three Question What do we want our final days to look like? Who do we want to be nears us? How can we support the E-O-L wishes of those closest to us?

POLST Websites Critical Conditions Planning Guide References CDC (2005). NCHS, National Vital Statistics System, Mortality. Accessed on Nov. 26, 2014 at:

Survey of Californians by the California HealthCare Foundation. (2012). Accessed on Nov. 26, 2014 at: Hale, J. (2013). Making Choices: Honoring Wishes. WellStar Ethics Department. Louisiana Physician Orders for Scope of Treatment. n.d. Guide to Advance Care Planning. GA Department of Human Resources. (2007). Georgia Advance Directive for Health Care. E%20DIRECTIVE%20FOR%20HEALTH%20CARE-07.pdf West Virginia Center for End-of-Life Care. (2012). Using the POST Form: Guidance for Healthcare Professionals. Heerema, E. (2013). Antibiotic Use in Advanced Dementia. Alzheimers/Dementia.

Coalition for Compassionate Care of California. (2011). Introducing the POLST. American Geriatric Society Geriatric Review Syllabus Teaching Slide-set 50

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