Illinoiss IDPH Uniform DNR Advance Directive New Documentation

Illinois’s IDPH Uniform DNR Advance Directive New Documentation for Patients & lity Care Revised 8/2/13

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Objectives The POLST Document By the end of this session, participants will be able to: • Understand the POLST Paradigm and how patient wishes are determined and documented in a standard form • Describe the relationship between a Power of Attorney for Healthcare and a POLST form, and when each is appropriate for patient completion • Recognize the importance of healthcare staff being properly educated regarding interpreting POLST forms during emergencies and other relevant circumstances 3

IDPH DNR Advance Directive… now meets national POLST standards • Illinois recently modified the current IDPH DNR Advance Directive to meet 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 4

POLST Use in the United States The POLST Paradigm is now in the majority of states 5 5

2000 Evolution of the IDPH DNR Form “Orange” DNR Form 2013 – POLST Go-Live • The IDPH approved form developed by a statewide consortium of providers, ethicists, and other stakeholders becomes widely available, pilot sites begin reporting data, and work on legislation continues. 2005 2006 2007 2012 2013 IDPH Uniform DNR “Order Form” IDPH Uniform DNR “Advance Directive” POLST Language Added IDPH DNR/POLST Utilized at State Level 6

Benefits of IDPH DNR/POLST in Illinois Promoting Patient-Centered Care • Promotes quality care through informed end-of-life conversations and shared decision-making • Concrete Medical Orders that must be followed by healthcare providers • Easily recognized standardized form for the entire state of Illinois • Follows person from care setting to care setting 7 7

Key Factors Work Together to Help POLST Work Color The pink color helps the form stand out for easier identification Location Transportability Designed to Organizations stay with the should assist person as the persons in person is choosing a transported to standard a new facility location in their & must be local area where honored in all POLST is kept locations 8

Why Does Illinois Need This Advance Directive? 9

To Insure Accuracy and Continuity of Patient Wishes Across Care Settings Ave. of 34 Physician Visits in last 6 months of life Ave. of 9 Different Physicians in last 6 months of life 10

Who is IDPH DNR/POLST Designed For? Focusing on patients as partners in their care. The POLST paradigm is designed for: § Persons facing life-threatening complications, regardless of age; and/or § Persons with advanced frailty and limited life expectancy; and/or § Persons who may lose the capacity to make their own health care decisions in the next year (such as persons with dementia); and/or § Persons with strong preferences about current or anticipated endof-life care. 11

Advance Care Planning • LTC facilities must now follow the regulatory mandates of advance care planning – F 155 Advance Directives – F 309 Quality of Life (End-of-Life) • Since the new form expands the number of options, including the ability to request CPR, POLST may support this type of planning • This version of the IDPH DNR/POLST form supports better discussions and can more accurately reflect the patient’s wishes 12 12

Current Advance Directives in Illinois: Patient IDPH DNR/POLST Directions for Emergency Treatment Power of Attorney for Health Care Chooses a person to make health care decisions 13 Mental Health Treatment Declaration Living Will Discusses choices for mental health treatment Says if I am actively dying and nothing more can be done, OK to stop treatment attempts

The IDPH DNR/POLST Form in Illinois

The IDPH DNR/POLST Document The POLST Document • 3 Primary Medical Order Sections A. CPR for Full Arrest • Yes, Attempt CPR • No, Do Not Attempt CPR (DNR) B. Orders for Pre-Arrest Emergency • Full Treatment • Limited Treatment • Comfort Only W E N C. Artificial Nutrition • None • Trial period • Acceptable W NE 15

The IDPH/DNR POLST Form in Illinois Physician Orders for Life-Sustaining Treatment A Cardio-Pulmonary Resuscitation (CPR) B Medical Interventions C Artificially Administered Nutrition D Documentation of Discussion E Signature of Attending Physician R Reverse Side – Contains More Information and Instructions 16

Section “A”: Cardio-Pulmonary Resuscitation Code Status – only when pulse AND breathing have stopped • There are multiple kinds of emergencies. This section only addresses a full arrest event (no pulse and not breathing). • Answers “Do we perform CPR or not? ” • NEW! Patients can use this form to say YES to 17 17

The IDPH/DNR POLST Form in Illinois Physician Orders for Life-Sustaining Treatment A Cardio-Pulmonary Resuscitation (CPR) B Medical Interventions C Artificially Administered Nutrition D Documentation of Discussion E Signature of Attending Physician R Reverse Side – Contains More Information and Instructions 18

Section “B”: Medical Interventions Do Not Resuscitate does NOT mean Do Nothing • Three categories explaining the intensity of treatment when the patient has requested DNR for full arrest, but is still breathing or has a pulse. • Comfort – patient prefers symptom management and no transfer if possible • Limited – no aggressive treatments such as mechanical ventilation 19 19

Stoplight Metaphor for Medical Interventions Stop – Caution – Go Follow Resident Wishes to: Stop Aggressive Treatment (Change focus to provide Comfort and Symptom management) Caution (Limited Treatment) Go (Full Treatment) 20

For Example… • 85 year-old woman is experienced increasing shortness of breath • She is increasingly hypoxic and may be confused • Staff want to know if they should be calling 911 and transport her to the hospital 21

POLST Clarifies Unclear Guidance • She has marked Comfort ONLY – Keep her at facility and – Pursue aggressive symptom management to keep her comfortable – Transfer only if comfort can not be achieved in current location • Patient marked Full Treatment – Call 911 and send to hospital 22

POLST Clarifies Unclear Guidance • Patient marked Limited Treatment – Depending on the resident’s exact wishes, and the facility’s acuity level, it may be appropriate to send her to the hospital for evaluation and possible treatment 23

Section “B”: Medical Interventions • Use “Additional Orders” for other treatments that might come into question (such as dialysis, surgery, chemotherapy, blood products, etc. ). 24 24

Section “B”: Medical Interventions “Check One” plus any Additional Orders • Note: The “Check One” instruction in Section B only refers only to the three primary choices. • You may also put instructions next to Additional Orders. • There is currently communication with IDPH asking them to remove the box next to Additional Orders to avoid this 25 25 confusion.

Section “B”: Medical Interventions Yes to CPR in Section A requires full treatment in Section B • If choosing “Attempt CPR” in Section A, Intubation and Mechanical Ventilation is required in Section B. – Why? If limited measures fail and the patient progresses to full arrest, the patient will be intubated anyway. 26

Section “A” choices influence medical interventions in Section “B” Section A Section B Yes! Do CPR Full Treatment Comfort Measures or DNR: No CPR Limited Interventions or * * Full Treatment *Requires documentation of a “qualifying condition” ONLY when requested by a Surrogate. 27

Quick Refresher on Decision-Maker Priority Start at the top and move down the list 1. Patient • Do not move on until patient has been evaluated by the attending physician who documents the patient lacks decisional capacity and is not expected to regain capacity in time to make this decision 2. Power of Attorney for Healthcare • Patient has completed and signed this Advance Directive 3. Surrogate (when you can’t speak to patient and no Po. A) • • Guardian of the person Spouse/ Civil partner Adult children Parents Adult siblings Grandparents/Grandchildren Close Friend

This Form Can Also Be Completed by a Po. A or a Healthcare Surrogate • Ideally, the form should be completed by the resident and reflect his or her choices • If completed by a Po. A, s/he can make any choice on the form that s/he feels the resident would make for himself or herself • If completed by a Surrogate: – S/He can complete Sections A and C at any time – S/He can choose Full Treatment in Section B (intubation and mechanical ventilation) at any time – The choices of Limited or Comfort in Section B MUST be accompanied by documentation of a “qualifying condition” 29 29

Healthcare Surrogate “Qualifying Condition” • Two physicians must document in the medical record that the resident has one or more of these conditions: – Terminal condition – Permanent Unconsciousness – Incurable or Irreversible Condition 30 30

Creating More Accurate Orders · Facilities will need to create orders to better capture the distinction of these categories, such as DNR-Comfort, DNR-DNI, or DNRFull Treatment. 31

Don’t Forget DNR for Procedures… Best Practice: DNR Is Not Automatically Lifted • Consent needs to be obtained to change an existing DNR order to full code, even during a procedure • Discuss appropriateness of DNR in light of procedure and objectives • If suspended, specify length of time • Many physicians will not perform procedures unless they have the ability to reverse a condition caused by the procedure itself 32

The IDPH DNR/POLST Form in Illinois Physician Orders for Life-Sustaining Treatment A Cardio-Pulmonary Resuscitation (CPR) B Medical Interventions C Artificially Administered Nutrition D Documentation of Discussion E Signature of Attending Physician R Reverse Side – Contains More Information and Instructions

Section “C”: Artificially Administered Nutrition • Nutrition by tube can include temporary NG tubes, TPN, or permanent placement feeding tubes such as PEG or J-tubes. • A trial period may be appropriate before permanent placement, especially when the benefits of tube feeding are unknown, or when the patient is undergoing other types of treatment where nutritional support may be helpful. 34 34

The IDPH DNR/POLST Form in Illinois Physician Orders for Life-Sustaining Treatment A Cardio-Pulmonary Resuscitation (CPR) B Medical Interventions C Artificially Administered Nutrition D Documentation of Discussion E Signature of Attending Physician R Reverse Side – Contains More Information and Instructions

Section “D”: Documentation of Discussion • The form can be signed by: • The patient (resident) • The agent with a Po. A (when the resident does not have decisional capacity) • The designated Healthcare Surrogate • When the resident does not have decisional capacity and has no Po. A or applicable Advance Directive • A guardian is also a surrogate 36

Decisional Capacity It’s not all or nothing. • Before turning to a Po. A or Surrogate, assess and document Decisional Capacity. • The resident may be able to make some decisions even if s/he can’t make all decisions. – Studies consistently show that decisions made by others are more aggressive and not as accurate as what the person would choose for him/herself. 37

Section “D”: Documentation of Discussion • According to IDPH, “one individual, 18 years of age or older, must witness the signature of the patient or his/her legal representative’s consent. . . A witness may include a family member, friend or health care worker. ” • When the form is completed by a person other than the resident, it should be reviewed with the resident if the resident regains decisional capacity to ensure that the resident agrees with the provisions. 38

Section “D”: Documentation of Discussion • Adults with an IDPH DNR/POLST are also encouraged to complete a Power of Attorney (Po. A) to make all other types of decisions. • Extreme care should be exercised if the Po. A or Surrogate wishes to reverse the direction of care chosen by the patient (in other words, the Po. A is trying to force treatment the patient has already refused) – For example, the patient requested Comfort or Limited Treatment, but the Po. A or Surrogate wants Full Treatment – Changes to a form should be based on evidence of the patient’s wishes 39

The IDPH DNR/POLST Form in Illinois Physician Orders for Life-Sustaining Treatment A Cardio-Pulmonary Resuscitation (CPR) B Medical Interventions C Artificially Administered Nutrition D Documentation of Discussion E Signature of Attending Physician R Reverse Side – Contains More Information and Instructions

Section “E”: Signature of Attending Physician • The attending physician must sign and date the form for the medical orders to be valid. • “Attending physician means the physician selected by or assigned to the patient who has primary responsibility for treatment and care of the patient and who is a licensed physician in Illinois. If more than one physician shares that responsibility, any of those physicians may act as the attending physician. ” 755 ILCS 40/10 41 41

Requirements for a Valid Form Use White or Ultra Pink paper • Patient name • Resuscitation orders (Section “A”) • 3 Signatures – Patient or legal representative – Witness – Physician • All other information is optional • Pink paper is recommended to enhance visibility, but color does not affect validity of form • Photocopies and faxes ARE acceptable. 42

What If the Resident Does Not Want to Fill Out One of the Sections? • Section A (requesting CPR or DNR) is the only required section • Cross out any other section and mark “No decisions made” – If left blank, boxes could be filled in later, effectively creating a physician order that the physician is unaware of or may not agree with – Makes it clear that resident or legal decision-maker chose not to address the subjects in that section – decisions can be made at a later date by creating a new form 43

Who Can Assist in Preparing the Form? · Best practice suggests use of those trained in the POLST Conversation such as (among others): – – – – • Physicians Social Workers Nurses Chaplains Care Managers Ethicists Physician Assistants and Nurse Practitioners Find an example of a POLST conversation at: http: //www. uctv. tv/search-details. aspx? show. ID=18360 44

POLST is a Process, Not a Form The form is a documentation tool. · POLST should not be used as a check-box form, or as a replacement for an informed conversation between residents, families and providers to: – Identify goals of treatment. – • Make informed choices. The conversation should be documented in the medical record, along with a copy of the completed IDPH DNR/POLST form. 45

The IDPH DNR/POLST Form in Illinois Physician Orders for Life-Sustaining Treatment A Cardio-Pulmonary Resuscitation (CPR) B Medical Interventions C Artificially Administered Nutrition D Documentation of Discussion E Signature of Attending Physician R Reverse Side – More Information and Instructions

Reverse Side: Guidelines and Instructions Completion of the form is always voluntary. 47 47

Potential System Concerns Facilities will want to have policies or protocols to address these issues: 1. Signing physician has not signed the form yet 2. Difficulty getting in touch with legal decision-maker to get form completed 3. The need to create appropriate facility orders that accurately reflect the wishes captured in all of the sections of the POLST form (A, B, & C) 4. Developing best practices for storing, locating, and transmitting document between care settings – Institutions should standardize where the document is located so that it is easily available during an emergency, but also protects the patient’s privacy 48

What Should I Do with an Older IDPH DNR Form? · Continue to follow valid older IDPH DNR Advance Directives. · Update the older form to the new form when it is feasible and file the older form in the purged medical record. · Review the form with the patient or legal representative when a change in the patient’s medical condition, goals, or wishes occurs 49

This presentation for the POLST Illinois Taskforce has been made possible by in-kind and other resources provided by:

Training Events • If you are attending a formal POLST training event, PLEASE help us with our quality improvement efforts and grant obligations by: – Signing in for attendance – Complete your survey and turn it in – Look for and complete a follow-up email in about 6 weeks 51

THANK YOU! Original presentation developed by Kelly Armstrong, Ph. D for the Illinois POLST Taskforce. Contact: karmstrong@siumed. edu