Iowa Physician Orders for Scope of Treatment (IPOST):

Out of Hospital DNR Orders for Terminally Ill Children

A. Paige Volk, MDAugust 13, 2012

Objectives

• Patient stories – Until 7/1/2012, Iowa’s children with terminal illness

were at risk for unwanted resuscitation at end of life• Update on new Iowa law: Iowa Physician

Orders for Scope of Treatment – UICH palliative care committee part of a state-wide

coalition committed to protecting the end of life wishes of medically fragile or terminally ill children

• How do I use the IPOST form?

UICH Patient Stories

• PW, 2 yo with unknown neurodegenerative disorder– Requested OOH DNR order from PICU physician

• JC, 7 mo with Spinal Muscular Atrophy type I– Home with OOH DNR wishes documented by

Pediatric Neurologist– EMS activated for respiratory arrest, died after 3

week hospitalization

UICH Patient Stories• AD, 2 yo with hypoxic ischemic encephalopathy →

recurrent acute life threatening respiratory events– Family requested OOH DNR, made aware of current policy– Died at home with hospice services

• CW, 5 yo with unknown neurodegenerative disorder– Recently moved to Iowa from Wisconsin – Carried OOH DNR with Medic Alert bracelet in Wisconsin– Local pediatrician signed IA DPH OOH DNR form in error– Family believed that child was protected from unwanted

resuscitation

• UICH Pediatric Faculty Members (N=54)– 94% of respondents think it would be beneficial to

explore a change in Iowa’s OOH DNR policy • IA Chapter of American Academy of Pediatrics

Members (N=42)– 95% of respondents support a change in OOH DNR

policy for pediatric patients in Iowa • IA EMS Providers (N= 190)

– 93% of respondents indicate that a change in Iowa’s OOH DNR policy would be beneficial

UICH, IA AAP and EMS Survey Results

IPOSTIowa Physician Orders for Scope of Treatment

Intention: Include provisions in Iowa code relative to existing DNR/ advance directivesRecipients: Intended for individuals who are frail and elderly or who have a chronic, critical medical condition or a terminal illnessCaveat: Does not change current definition of “Qualified patient,” which is a person over age 18 years with a terminal condition

IPOSTIowa Physician Orders for Scope of Treatment

How are children affected? Children in Iowa have never had DNR or advanced directive protections For children, no other orders/laws supersede IPOST

IPOST is age-nonspecific, allows a person to communicate their preferences at end of lifeIPOST includes sections on: Resuscitation; General Scope of Treatment; Artificial Nutrition; Etc…

IPOST FORMIowa Physician Orders for Scope of Treatment

IPOST FORMIowa Physician Orders for Scope of Treatment

UICHPalliative Care GroupEducational Initiative:

Facts Document

Endorsed by:UICHEMSC

UICHPalliative Care GroupEducational Initiative:

FAQ Document

Endorsed by:UICHEMSC

Questions and Discussion

http://www.idph.state.ia.us/ipost/Form.aspx

Interested Parties/Affiliations Supporting IA OOH DNR Educational Initiative:

• American Academy of Pediatrics (AAP)-- Tess (Maria) Barker, Executive Director-- Debra Waldron, MD (IA Chapter—AAP president)

• Child Health Specialty Clinic (CHSC)-- Debra Waldron, MD-- Barbara Kahl, Program Manager

• Emergency Medical Services for Children (EMSC)-- Katrina Altenhofen, MPH (State Director-IDPH Bureau of EMS EMSC Program)

• Iowa Association of County Medical Examiners (IACME)-- Dennis Mallory, MD (Board Member)-- Marcus Nashelsky, MD (UIHC Medical Examiner)

• UI Children’s Hospital-- Paige Volk, MD (Pediatric Critical Care)-- Dianne Atkins, MD (Pediatric Cardiology)-- Janine Petitgout, ARNP (Continuity of Care, Peds Palliative Care Director)-- Sheila Frascht, RN (Nurse Clinical Specialist, Peds Palliative Care)