FINE TUNING THE POLST SYSTEM: THE CASE OF AN INVALID,

CONTRADICTORY POLST FORM

Alvin (Woody) Moss MD, WVU Center for Health Ethics and Law*Margaret Carley JD, RN OHSU Center for Ethics in Health Care*        Terri Schmidt MD, MS, Oregon Health & Science University (EMS)*

Paul Schneider MD, VA Medical Center, Los Angeles, CAKenneth Zeri RN, MS, Hospice Hawaii*

*National POLST Paradigm Task Force members1

Current as of January 3, 2012

www.polst.org2

A 78 year-old woman was admitted from a nursing home with chest pain. She had a past history of coronary artery disease status post stent placement, congestive heart failure, hypertension, lipid disorder, and mild dementia. A POLST form accompanied the patient and indicated CPR in Section A and limited additional interventions in Section B. The attending physician wondered what he should do with the POLST form because Section A and Section B seemed to be contradictory. The POLST form had been prepared by a social worker who had signed it, but there was no physician signature on it.3

In transporting the patient, EMS worried, “What do I do if she codes and I do CPR and get her back, but she is not breathing normally? Do I intubate her?” The ED physician wondered the same thing, but fortunately she did not suffer a cardiac arrest.

When interviewed by the palliative care team who was consulted to address the POLST form inconsistency, the patient indicated that she would not want to be kept alive on machines and when it was explained to her that if she had CPR and lived through it, it was very likely that she would end up being on a breathing machine. She said, “Well then, I don’t want CPR.”

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The patient was questioned, and she clearly understood that without CPR in the event of a cardiorespiratory arrest she would die. She was felt to have decision-making capacity for her decision. A daughter who lived out of state was the patient’s Medical Power of Attorney representative and wanted her mother to have CPR.

What should be done with regard to the seemingly contradictory POLST form and the conflict between the patient and her daughter? How could these situations be prevented in the future?5

Where Was the Problem in This Case?Can we expect POLST preparation to be

any more accurate/functional than the rest of our somewhat inaccurate/dysfunctional system? If so, how? Who should “own” POLST and what control should they exert?

In code discussions, when will providers demonstrate the moral courage to use the word “die”? “If God forbid you were to die during this hospitalization, would you want us to try to bring you back from death?”

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Where Was the Problem in This Case?What was the role of the physician in this

case? The SCBCC struggled mightily over this question and concluded physicians must at least personally confirm the discussion when initially prepared by a non-physician. My hospital mandates an MD POLST discussion. VA does not allow resident, licensed physicians to sign DNR orders > 24 hrs. Therefore, they should not sign most POLSTs.

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Does the patient have capacity ?Does the patient have capacity

How, when and who would make this determination this in your state?

When can the appointed health care representatives begin to make health care decisions?

What happens if the patient does not have capacity and there is no one available to make health care decisions?

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Can a family member override the existing POLST Orders?State by state variations attributable to

different advance directives and surrogate decision maker statutes

May depend on if your POLST program is statutory, regulatory or voluntary

Outside the hospital it may depend on your out-of-hospital DNR statute or rules

May depend upon statutory or regulatory limitations based on the client’s medical conditions

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May Be Multiple Family Member Roles Informal roles of family members

Primary Caregiver Primary Decision Maker Spokesperson Out-of-Towner Patient Wishes Expert Protector/Vulnerable Member Health Care Expert

End-of-Life Decision Making in Adult ICUs: Roles & Relationships of Key Players

Judith Gedney Baggs, PhD, RN, FAAN

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Minimizing or avoiding conflicts by a better goals of care conversation

Advance Care planningGoals of CareCommunication

What do patients and families want?Better communication by clinicians

Timely, on-going, clear, complete, compassionate

Address condition, prognosis, treatmentsPatient-focused health care decision making

Aligned with patient values, care goals, preferences

Nelson, Puntillo, et al. (2010), In their own words. Critical Care Medicine11

.Was this a burdensome transition of care from nursing home to hospital? “Health care transitions, such as the hospitalization of nursing home

residents, have the potential for fragmentation of care, changes in the management of chronic diseases, duplication of diagnostic workups, and medical errors.”

NEJM Study Results Among 474,829 nursing home decedents, 19.0% had at least one

burdensome transition(range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an

advance directive were at increased risk. Nursing home residents in regions in the highest quintile of

burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube, have spent time in an ICU in the last month of life have a stage IV decubitus ulcer , or have had a late enrollment in hospice.

Gozalo P, Teno JM, Mitchell SL, et al. End-of-Life Transitions among Nursing HomeResidents with Cognitive Issues. N Engl J Med 2011;365:1212-21.12

EMSConflicting Section A and B orders

Section A DNR Section B Full Treatment

Section A Resus Section B Comfort MeasuresSection A Resus Section B Limited

Interventions

What should EMS do?

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What is the trump card?POLST formPatient choiceFamily/surrogate choice (Does it matter if

it is a legal guardian? Power of attorney for health care?)

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Hospice CareStaff must know basic laws governing

POLST in stateHospice care across most settings

Home, SNF, Hospital, Care Home, Hospice Facility, Homeless

POLST “Form” may be voluntary for healthcare institutions to use, but POLST “Orders” may be mandatory to follow

Legal requirements for correct document

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Hospice CareHome based care

Clarifying goals for care Including family

Policies regarding completing formsNursing Facility / Hospice Collaboration

Support Facility staff in review & clarification of POLSTHospice team (MD, RN, MSW) support resolution

of conflictPolicies governing use of form

POLST is voluntary

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Regional lunch discussions

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RegionsCalifornia – Aviary BallroomMidwest – Beach South

IL, IA, MN, NE, MO, MI, OH, WINortheast – Beach South

DE, ME, NH, NJ, NY, PA, RI, DCSouth – Beach South

FL, GA, KY, LA, NC, TN, TX, VA, WVWest – Beach South

CO, HI, ID, MT, NM, OR, UT, WA

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