the new idph uniform dnr advance directive...ems, the dnr order had to be rewritten at each new...
TRANSCRIPT
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The NEW IDPH Uniform
DNR Advance Directive
AN INTRODUCTION FOR
EMERGENCY MEDICAL
SERVICES Revised August 2013
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The POLST Document
• Explain the POLST Paradigm and how patient
wishes are documented in a standard form
• Determine how IDPH DNR/POLST
documentation builds upon and improves existing
advance directives
• Recognize the importance of EMS personnel
being properly educated regarding interpreting
IDPH DNR/POLST forms during emergencies and
other relevant circumstances
Objectives
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Patient
IDPH DNR/POLST Directions for
Emergency Care
Power of Attorney for Health Care
Agent (rarely contains directions
for physician)
Mental Health Treatment
Declaration
Directions + Agent (for physician)
Living Will Directions
(for physician)
Turn to Advance Directives only if the patient
cannot make medical decisions:
Apply to ALL healthcare providers,
including EMS
Current Advance Directives in Illinois:
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• March 14, 2013 IDPH released a new DNR
Advance Directive to come closer to the national
POLST standards used in other states
• POLST stands for “Physician Orders for Life-
Sustaining Treatment”
• POLST reduces medical errors by improving
guidance during life-threatening emergencies
IDPH DNR Advance Directive…
and national POLST standards
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POLST Use in the United States The POLST Paradigm is now in the majority of states
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• Older DNR forms may not be specific enough
to guide EMS in different emergencies
• Other Advance Directives are not medical
orders that EMS personnel are legally
allowed to follow
• The new IDPH DNR/POLST form addresses
these concerns
Concerns about other
non-POLST Advance Directives
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Benefits of new DNR/POLST in IL
• Concrete Medical Orders
that must be followed by
healthcare providers
• Easily recognized
standardized form for the
entire state of Illinois
• A single form goes with
the patient from care
setting to care setting
Promoting Patient-Centered Care
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The POLST Document
4th version of IDPH DNR form
2000: 1st Illinois out of hospital DNR “orange form.” Only for
EMS, the DNR order had to be rewritten at each new facility.
2005: IDPH Uniform DNR Order form - applied to all facilities
and a patient only needed one form.
2006: Some facilities confused if form had to be used for every
in-hospital DNR order (it did not), so it was renamed the
IDPH Uniform DNR Advance Directive.
2013: Still called the IDPH DNR Advance Directive, but some
people may use the shorthand POLST since it uses that
way of talking to patients and documenting wishes (the
POLST “paradigm”) for life-threatening emergencies.
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ALL previous versions of the
form are still VALID!!
• Some persons may still have older versions of the form
• A valid, completed form does not expire
• Do NOT have to have the original form – all copies of a valid form are also valid
• Form should travel with patient at all times
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What if there are 2 or
more different forms?
• When a new form is created, it voids past
forms
• Follow the instructions on the form with the
most recent date
• EMS is not responsible for investigating
presence of other forms - work with the
form that is presented as truthful
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• NO.
• It is recommended that the form be printed
on pink paper – this is only to make it
easier to see
• All copies of the form are valid, regardless
of color
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Does the Color of the Form Matter?
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The IDPH DNR/POLST Form in Illinois
The POLST Document
• 3 Primary Medical Order Sections – CPR for Full Arrest
• Yes, Attempt CPR • No, Do Not Attempt CPR (DNR)
– Orders for Pre-Arrest Emergency • Full Treatment • Limited Treatment • Comfort Only
– Artificial Nutrition • None • Trial period • Acceptable
The New IDPH DNR/POLST Form
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• Old form: DNR only
• New form:
– “CPR” or
– “DNR + Level of Intervention” (in section B)
• There are now more ways to tailor the
form to individual medical conditions
and/or wishes
Section A CPR: Yes or No
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• Persons with advanced age or disabilities
may be concerned they will not receive the
same emergency services as younger or
non-disabled persons, despite having a good
quality of life
• Some persons may have created a DNR
form during a period of serious illness, but if
they recover or go into remission, they may
want to create a form now requesting CPR
CPR is the Default Why use the form to request CPR?
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Section “A”: Cardio-Pulmonary Resuscitation
• Section A only addresses a full cardiac arrest
(no pulse and not breathing)
• Answers the question “Do we do CPR or not?”
Code Status – only when pulse AND breathing have stopped
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Section “A”: Cardio-Pulmonary Resuscitation
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Code Status – applies when breathing AND pulse have stopped
• If “Attempt Resuscitation” box is checked, do
NOT need to look at other parts of the form.
• Initiate full resuscitation/CPR per SOP/SMO
• If “DNR” box is checked, and patient is in full
arrest, “Stop” and do not begin CPR
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Section “B”: Medical Interventions
• The 3 categories in Section B explain the
intensity of emergency treatment for persons
marking DNR in Section A (full arrest), but
who still have a pulse and/or breathing (not
full arrest)
Do Not Resuscitate does NOT mean Do Not “Treat”
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Stoplight Metaphor for Medical Interventions
Comfort Only (No Advanced Airway, Compressions, or Aggressive Treatment)
Caution (No Advanced Airway)
Permissible (Full Treatment per SOP/SMO as Indicated)
Stop – Caution – Go
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Section “B”: Medical Interventions
• “Comfort Measures Only” - maximize comfort, treat pain and distress according to form options.
• Patient prefers not to be transported, but once EMS is called, s/he
may need to be transported anyway.
• Consult with Medical Control (OLMC) to determine appropriate course
of action. Try to maximize comfort in existing location and transport
only if comfort needs cannot be met in current location. 21
Section “B”: Medical Interventions
• Limited Additional Interventions: Comfort
Measures plus basic medical interventions, incl:
• CPAP, BiPAP, IVF, ECG monitor
• Transport to hospital if indicated
• No intubation, advanced airways, bag valve
mask, or mechanical ventilation 22
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Section “B”: Medical Interventions
• Intubation and Mechanical Ventilation: provide full treatment • A patient may want DNR for full arrest but still want
everything done if they still are breathing or have a pulse.
• If “Attempt CPR” is marked in Section A, treat per SOP/SMO and follow instructions for Intubation and Mechanical Ventilation in Section B (if something else is marked here it is a mistake! ) 23
Section “B”: Medical Interventions
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• “Additional Orders” is used to customize the form for
individual medical conditions when necessary
• Only carry out orders that fall within your SOP/SMO
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Section “C”: Artificially Administered Nutrition
• EMS providers can usually ignore this
section
• For patients with TPN/tube feedings needing
transport, contact Medical Control
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Section “D”: Documentation of Discussion
• Need 2 signatures in section D. • Patient or legal representative • Witness
• If signed by the patient’s legal representative, supporting documentation that identifies the legal representative does NOT need to be verified 26
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Section “E”: Signature of Attending Physician
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• The form must have a physician’s name and
signature, and the effective date to be valid
• The physician’s signature may be written by a nurse
who also uses her/his own initials - this is acceptable
and does not affect the validity of the form 27
• Patient name
• Resuscitation orders (Section “A”)
• 3 Signatures
– Patient or Legal Representative signature
– Witness signature
– Provider signature and name
• Date
• All other information is optional
Requirements to Make the Form Valid 3 Signatures are Required
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• The patient at any time
• For all other situations, it is a complicated process
that may take more time to figure out
• If you have time, call Medical Control (OLMC)
– A PoA or Surrogate should not overturn decisions made,
documented, and signed by the patient
• You are legally protected if you follow the orders
on a valid form in good faith
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Who Can Revoke these Orders?
• Determine if the person disputing the order is:
1. the designated PoA or Surrogate, and
2. if s/he was the one that signed the original DNR order.
• If yes to both: The PoA or Surrogate may withdraw the request for DNR and resuscitation should occur.
• If no to either element: Follow the orders on the DNR form. Contact OLMC for additional orders.
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What if a family member disputes a
valid DNR order?
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“A health care professional who in good faith complies with a do-not-resuscitate order made in accordance with this Act is not, as a result of that compliance, subject to any criminal or civil liability, except for willful and wanton misconduct, and may not be found to have committed an act of unprofessional conduct.”
Illinois Health Care Surrogate Act
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Are EMS personnel at Risk for
following a DNR Order?
Reverse Side: General Information
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May provide useful contact phone numbers.
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Quick Recap
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Yes, No, How Intense?
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Do or Do Not?
How Intense?
Ignore
Where do you look?
• You are called to an emergency in a person’s home and find a gentleman lying in his own bed. He is not breathing but does have a shallow pulse.
The IDPH DNR form is on the fridge. What instructions are you looking for? A. Section A: has the patient marked DNR?
B. Section B: how aggressively does the patient want to be treated?
C. Section C: has the patient consented to artificial nutrition?
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Where do you look?
• You are called to an emergency in a person’s
home and find a gentleman lying in his own
bed. He is not breathing and has no pulse.
The neighbor has already started CPR. The
IDPH DNR form is on the fridge. What
instructions are you looking for?
A. Section A: has the patient marked DNR?
B. Section B: how aggressively does the patient
want to be treated?
C. Section C: has the patient consented to artificial
nutrition? 35
This presentation for the POLST Illinois Taskforce has been
made possible by in-kind and other resources provided by:
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THANK YOU!
Original presentation developed
by Kelly Armstrong, PhD
for the Illinois POLST Taskforce.
Contact: [email protected]