POLST, and Advance Directives, in

Context of a Physician Patient

Relationship

Shelly K. Huston LSW,CCM,CCP,

MBA-HCM
 Federal Law History
1985 DNR order for terminal patients
1990 Patient Self Determination Act
1990 Uniform Act of the Terminally Ill allows for
Declaration (Living Will)
1993 Uniform Health Care Decisions Act
recognizes default surrogates in absence of
an advance directive requires witnessing
1997 Health Care Proxy and Durable Power of
attorney for Healthcare
 Nevada Law History
EMS Out of Hospital DNR - A.B. 173, Chapter
157. Effective July 1, 2001
2007 Attorney General registers advance Care
documents electronically The Lockbox created
2011 Nevada Supreme Court rules on Maxey
Oct 1,2013 AB 344 Creates the POLST Final
document published April 2014 NRS 162
 Nevada POLST is advocating
for changes
Clarify document date and signature
Have Non Physician practitioners APN
and PA able to sign the form
Allow Surrogate to complete POLST if
patient is unable and no Advance Directive
(27 states allow this)
Change competency to capacity in the law
Resolve conflicts of EMS law and Ch. 162
Transforming Preferences into Medical Orders
Orders related to end of life care should be
a patient-centered process
Begin with patient and family values
Physician conversation regarding prognosis
and plan
Result in medical orders that match patient
preferences
And are portable across care settings
 Physician Order for Life Sustaining Treatment
(POLST)
Designed to improve the quality of care people receive at
the end of life by turning patient goals and preferences for
care into medical orders
Turns the wishes of an individual into actionable medical
orders that apply in and out of the hospital.
Appropriate for people who currently have a serious illness
foreseeable to be terminal within 2-3 years
Is not an advance directive and does not satisfy a hospitals
responsibility to offer an advance directive to patients.
Source: www.polst.org
 Clearing up the confusion:
Which document is appropriate?
ADVANCE DIRECTIVE- Insurance against we never talked
about that
Allows every adult regardless of health condition to name a
health care agent to act in their place (substituted
judgment) in ADVANCE of an illness
Specifies preferences for medical treatments IF one become
s seriously ill and lose s decisional capacity
Gives instruction to caregivers and health care providers in
broad terms effective in the future
Ifthen statements called a springing power of attorney
effective in the future upon incapacity as determined by the
physician.
 Clearing up the confusion:
Which document is appropriate?
POLST- optional power-up to the Advance Directive
Useful for people who have a terminal or multiple illness,
who may be in the last years of life, frail elderly
Very specific instructions on medical treatments
effective as doctors orders as soon as the doctor signs
them and patient cant make decisions.
POLST gives orders based on current condition effective
in all settings and are effective regardless of physician
privledges
POLST is not appropriate for persons with stable medical
or functionally disabling problems who have many
years of life expectancy.
Source: www.polst.org
 Clearing up the confusion:
When do these documents take effect?
ADVANCE DIRECTIVE
Takes effect only when patient can no longer make his
or her own medical decisions; designated health care
agent would be called on to make decisions
Next of kin, Healthcare proxy or Physician uses Living Will
to make decisions about medical treatments as guided
by continued dialogue
Health care agent may ask for a POLST, as guided by
patients expressed wishes in the Living will portion of
the Advance Directive. If patient is within 2-3 years of
dying physician must complete it or hand off patient
 Clearing up the confusion:
When does the document take effect?
POLST
Takes effect immediately when presented to
healthcare staff Orders are re-written on chart
Does not need confirmation if presented; its a
bonefide physician order regardless of location
Validity does not depend on signing Physician
being credentialed where the patient is at the time
The patient takes the original and leaves a copy.
 POLST in the ER
California Hospital Association (May 2010): In the
instance where a patient arrives at the ED with a
completed POLST, the receiving physician must assess
the patient and the current circumstance and issue
new orders.
Centers for Medicare and Medicaid Services has
informed CHA that patient treatment provided by a
hospital, including services provided in the emergency
department, must be ordered by physicians who are on
staff and privileged at that hospital. The treating
physician at a receiving hospital still has the
responsibility of adequate patient assessment and
documentation including comfort care and pain
management
 Deuling Documents
What does Nevada Law say?
If the Advance Directive and POLST
conflict then go by the one completed
most recently
If the POLST says provide Resuscitation
and the pt has a DNR on his person the
healthcare provider honors the DNR and
does not provide life sustaining treatment.
 Story of Jim Option 1
Age 70
Good health has mild CAD and COPD uses O2 at night
I dont like the idea of being hooked up to
machines. When its my time to go, just let me go.
Completes advance directive, names wife as health
care agent
Says no to life support if terminal, comatose or burdens
outweigh benefits of treatment
Advance directive placed in Jims medical record
Collapses at family gathering,
Heart stops
What happens next?
EMS called, ACP presented- Have to intubate per law
 Story of Jim Option 1
Doctor provides treatment (including life support) to
stabilize Jim while diagnostic tests done,admitted
Doctor consults with Jims wife, who is the designated
healthcare agent
Depending on burden/benefit and terminal dx doctor
advises DPOA of options
DPOA decides on treatment going forward based on
Jims advance directive and prognosis
Pt may need decision by DPOA on removing life
support
Comfort care initiated removed from life support
 Story of Jim Option 2
Age 70
Good health has mild CAD and COPD uses O2 at night
I dont like the idea of being hooked up to
machines. When its my time to go, just let me go.
Goes to doctor, has a conversation face to face
and selects all options to decline life support
Doctor signs POLST
POLST is placed in Jims medical record
Jim collapses at family gathering, He has his POLST in
the car
Heart stops
What happens next?
EMS called- oxygen and comfort measures applied
 Story of Jim Option 2
DPOA presents POLST to EMS/MD
EMS reads Jims POLST: Do not attempt resuscitation;
comfort measures only; and no artificial nutrition by
tube. Contacts ER Physician to inform of wishes
Jim receives no life support treatment
Goes to ER with oxygen
Pronounced or comfort measures and Hospice
What are some of the
implications for the Patient
and family?
Questions or Comments?
THANKS FOR PARTICIPATING