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POLST and HospiceAn Update for Oregon
Gary Plant MD FAAFP
Madras Medical Group
Oregon POLST Task Force
Oregon Academy of Family Physicians
Patient-Centered Primary Care Institute
Online Modules
Webinars
Website
Learning Collaboratives
Trainings
TA Network
Learning Objectives
By the end of the workshop, the learner will:
• Understand who should have a POLST form
• Understand how to complete and sign a POLST
• Know what to do with the completed POLST• Recognize the POLST as a tool for clarifying the
patient’s wishes for end-of-life care
What is POLST?
• Physician Orders for Life Sustaining Treatment
• A tool for clarifying the patient’s wishes for care at the end of life
• Legal orders that can be followed by emergency personnel to provide only the care desired by the unresponsive patient
New Registrants by County: 2014Includes only registrants that provided address information and reside in Oregon
New Registrants Mapped 22, 047 (71.6%)New Registrants Unmapped 8,742 (28.4%)----------------------------------------------------Total 30,789
Proportion of County Population over age 65 with Active POLST in Registry
5/3/09-12/31/14 Data as of 1/12/15Includes only registrants that provided address information and reside in Oregon
New Registrants Mapped 74,176 (64%)New Registrants Unmapped 41,715 (36%)--------------------------------------------------------Total 115,901
Developing Programs
National POLST Paradigm Programs
Endorsed Programs
No Program (Contacts)
*As of January 2015
Mature Programs
Regionally Endorsed Program
www.polst.org
Programs That Do Not Conform to POLST Requirements
POLST Is Changing the National Paradigm
Who Should Have a POLST?
If you would not be surprised by the patient’s death within the next year,
consider completing a POLST
• Elderly, frail, declining
• Terminal disease at any age
• Adamantly declines resuscitation at any age
How Advanced Directives and POLST Work Together
Age 18
Complete an Advance Directive
Update Advance Directive Periodically
Diagnosed with Advanced Illness or Frailty(at any age)
Complete a POLST Form
Change in health status
May Complete a new POLST Form
Treatment Wishes Honored
Oregon 2014 POLST form
Section A: Cardiopulmonary Resuscitation
• Patient is unresponsive, pulseless, and not breathing
• Attempt resuscitation (CPR) or not (DNR)• Required for submission to registry
Oregon 2014 POLST form
Section B: Medical Interventions
• Patient has pulse and is breathing
• Clarifies the level of intervention desired by the patient
Oregon 2014 POLST form
Section B: Medical Interventions
• Comfort Measures Only: focus on relief of pain and suffering (most common for Hospice)
• Limited Treatment: treat easily corrected problems with medications, fluids, etc (may be appropriate for some Hospice patients)
• Full Treatment: focus on prolonging life through all available measures (typically not appropriate for Hospice)
Section C: Artificially Administered Nutrition
• Always offer food and drink by mouth if feasible
• Long-term artificial nutrition is typically not appropriate for Hospice patients
• Most patients choose no artificial nutrition
• Defined trial period of artificial nutrition may be appropriate in limited Hospice situations
Oregon 2014 POLST form
Section D: Documentation of Discussion
If the patient is unable to have a meaningful discussion of end-of-life wishes, document with whom you spoke to determine those wishes
Oregon 2014 POLST form
It is recommended (but not required) to have the patient or their surrogate sign the form to acknowledge their participation in the process
The 2014 POLST has an optional box to opt out of the POLST registry if the patient does not want their POLST submitted
Opting out of the registry greatly reduces the benefit of completing the POLST
Oregon 2014 POLST form
Oregon Law allows a POLST to be signed by an allopathic or osteopathic physician, a nurse practitioner, or a physician assistant
A valid POLST includes the printed name of the signing clinician, the signature, and the date that the form was signed
Oregon 2014 POLST form
What Happens Next with the POLST?
A completed POLST should be submitted to the Oregon POLST registry
Electronic submission may be coming soon, but currently a copy of the form must be faxed or mailed to the registry
A copy of the completed POLST should be included in the medical record
The original POLST goes with the patient to their home or accepting facility
Once entered in the Oregon POLST Registry, the patient will receive a letter in the mail including:
• A description of their answers to sections A, B, and C for validation
• A sticker with their registry number to place on the original POLST form
• A refrigerator magnet with their POLST registry number
What Happens Next with the POLST?
How Does It Work?
Scenario 1
EMT’s respond to a 911 call and find an unresponsive patient who is pulseless and not breathing. The patient has a POLST indicating no resuscitation. The patient’s wishes are honored.
If the POLST is not immediately available, EMT’s would begin resuscitation while contacting the POLST registry. If the registry has a POLST indicating no resuscitation, CPR would cease.
Scenario 2
A patient on Hospice is actively dying and unable to communicate verbally, but is moaning and writhing due to uncontrolled pain and has started having occasional seizures. The decision is made to transfer to the hospital for symptom management.
The POLST indicates DNR, comfort measures, and no artificial nutrition.
What constitutes “comfort measures”?
How Does It Work?