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6/27/2017
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PALLIATIVE CARE,HOSPICE, ADVANCE CARE
PLANNING & POLST
Rajeev Kumar MD CMD FACPManaging Partner, Midwest GeriatricsChief Medical Officer, Symbria
Palliative Care
Palliative care aims to relieve suffering and improvequality of living and dying in patients who have aprogressive incurable disease.
At What Stage Should Palliative CareBe Considered?
DEATH
Diagnosis
Curative
Life-Prolonging
Illness Trajectory
Palliative Care
Old Model
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At What Stage Should Palliative CareBe Considered?
Diagnosis
Therapy tocure orcontroldisease Palliative
CareApproach
Illness Trajectory
Death
BereavementCare
End of Life CareTerminal phase
Current Model
The Challenge ofEnd-of-Life Patient Care
Everyone dies. Most medical doctors encounter
patients with terminal illnesses with regularityduring the course of their practice.
Impending death from an incurable illness is a
condition that neither patient nor physician wouldchose, yet given this situation…
Good care of patients at end-of-life can often
result in a meaningful period of personal growth forthe patient and family, and a rewarding experiencefor the physician.
Reality: End-of-life care is NotOptimal today
Physician skills are suboptimal in:
Alleviating suffering
End-of-life communication
Public partly to blame
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Why don’t we do a good job?
Not a major part of medical education…
Role of MD in care of dying not defined
Societal attitudes:
The “Culture of Medicine” (C. Cassell)
Traditional Goals ofthe Medical Profession:
To cure SOME
To relieve OFTEN
To comfort ALWAYS
The “Culture” of Medicine
Focus on “curing”
Public expects miracles
So does physician: Death of patient viewed as personal and / or
professional failure by doctors
Perception of public and medical community: Skills in palliative care are not highly valued
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Terminal illness…Modern Doctor’s Perspective
“Nothing more for me to do”
Care Beyond Cure:Palliative Care
The treatment of symptoms or sufferingcaused by an illness without attempting tocure the underlying illness
Usually done when curative therapy is noteffective, but can begin even whilepursuing curative therapies
Care Beyond Cure:
Palliative Care: focus on comfort.Dimensions:
Symptom management (e.g., controllingpain, nausea, improving breathing)
Physical therapy
Counseling for person and family
Spiritual support
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Training Present and FutureDoctors in End-of-life Care Symptom management
Communication re: disease outcomes,establishing goals of care…
Legal and ethical issues
Cultural awareness
Recognizing social and spiritual suffering
Hospice care – referring and working with theteam
When is a PC consult appropriate?
Chronic illnesses- COPD, CHF, ESRD,AD,CVA, NF residents,‘super old’ with life expectancy of 2 years or less.
Recurrent/Refractory sepsis, aspiration pneumonia, prolongedICU stay without improvement, vent dependency, frequenthospitalizations with poor quality of life.
Patients and families that need more education or a secondopinion about treatment options.
How can we make things better?Understand that
Palliative treatment that allows adignified and gentle death of aterminally ill patient is a medicalaccomplishment of considerablemerit, not a “failure”
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End-of-life care:Issues for the Public
Understand what HOSPICE careprovides
HOSPICECARE …
Program to deliver palliative care andpersonal support to individuals with life-limiting illness
Unit of care: patient and family
Not a place: hospice is where the patient is…
Interdisciplinary team approach
The Interdisciplinary Team (IDT)
Patient and family
Patient’s doctor
Medical Director
Nurse
Home health aide
Chaplain/pastoralcare specialist
Social Worker
Trained volunteers
Pharmacist
Physiotherapist
Occupational, speechtherapists
Music/art therapists
Dietician
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IDT Responsibilities
Manage the person’s pain and symptoms;
Provide emotional support;
Provide needed medications, medical supplies, and equipment;
Coach loved ones on how to care for the person;
Deliver special services like speech and physical therapy when needed;
Makes short-term inpatient care available when pain or symptoms becometoo difficult to manage at home, or the caregiver needs respite time; and
Provide grief support to surviving loved ones and friends.
…HOSPICE CARE
Services defined by Medicare Hospice benefit:
6 month or less life expectancy
Hospice responsible for costs of ALL care related to terminal illness…
Limitations of Hospice Care
Reimbursement system: Forces abrupt change from disease-focused care to palliative care →
Late Referrals Median LOS less than one month
End-stage of some illnesses not well served: Leukemias, lymphomas
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To learn more about Hospice
Visit the National Hospice and Palliative CareOrganization Website at
http://www.nhpco.org
End-of-life care:Issues for the Public
Effective methods to control symptoms anddistress are available
If you have pain or discomfort, TELL yourdoctor!
Ask medical team for clear and honestdiscussion of goals of care IN TERMS YOU CANUNDERSTAND
End-of-life care:Issues for the Public
Prepare Advance Directives now!
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Advance Care Planning
Advance directives – 2 parts (A, B) A: Appointment of HEALTH CARE AGENT
B: HEALTH CARE INSTRUCTIONS Living will
NO NEED FOR LAWYER or NOTARY Forms available on line
http://www.caringinfo.org/
Need 2 witnesses
ACP: What is it?
Advance Care Planning is a process of informed consent toidentify, document and communicate a person’s futuretherapeutic decisions based on:
Current and anticipated future medical condition(s)
Anticipated future medical decisions
Personal values and wishes
When and if that person no longer has decisional capacity
Discussion among patient, healthcare providers, usually family
Types of Advance Directives
Health Care Proxy
Durable Power of Attorney for Health Care
Living Will
Physician Orders for Life-Sustaining Treatment (POLST)—theseare actual medical orders Includes “POLST Paradigm” documents, including MOLST, MOST,
COLST, POST, T-POPP, etc. Usually recommended for people nearing end of life
May vary by state, but generally recognized and honored whenpresented
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Part A – Health Care Agent
A person you name in the Advance Directive:
They will make health care decisions on your behalf if you are nolonger able to make such decisions
Part B – Health Care Instructions
If my death from an incurable disease isimminent and even if life-sustaining proceduresare used there is no reasonable expectation ofmy recovery: I direct that my life not be extended by life-sustaining
procedures, including the administration of nutritionand hydration artificially
OR I direct that my life not be extended by life-sustaining
procedures, except that if I am unable to take food bymouth, I wish to receive nutrition and hydrationartificially
End-of-life care:Issues for the Public
Understand what “Do Not Resuscitate”means, and how this differs from an ADVANCEDIRECTIVE
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Advance Directives vs. DNR Order
A DNR order is written ONLY when the conditionsin the advance directive/living will apply “Terminal or end-stage condition”
“Persistent vegetative state”
MISCONCEPTION: A person with advance directives that instruct “no life
sustaining procedures” is automatically “DNR”
Important that YOU, YOUR HEALTH CARE AGENT andYOUR DOCTOR know this difference!
Health Care Proxy
Appoints individual (“agent”) to make health caredecisions when the patient lacks decisional capacity
May also appoint alternate agents
May stipulate specific conditions or allow for broaddiscretion (leeway)
Allows for the most flexible discretion when theagent is familiar with the patient’s values and wishes
Important to pick the right agent!
Advance Care Planning involves
Preparation Reviewing current conditions and prognosis (“surprise”
question) Families tend to overestimate life expectancy Misunderstanding of patient’s condition Belief in the patient’s unique strengths and beliefs Mistrust in health care providers due to cultural beliefs or past
experience
Physicians also tend to overestimate prognosis
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ACP Codes
• Voluntary—get and document permission/consent
• Billed in addition to other E/M and CPT codes
• No limit on how many times can be billed
• Physician/NPP can bill (incident-to rules apply)
• Must be face-to-face (with either patient or decision-maker)
• Remember 20% copay by beneficiary or secondary insurer- Except when doing Annual Wellness Visit, modifier -33, no copay
• Does not require any specific template or completion of any legal documentslike POLST/AHCD; document time and content
For primary care physicians can be an add-on to an AnnualWellness Visit with modifier -33 (in this case no 20% co-pay)
When will CMS Cover ACP?
“When the described service is reasonable and necessary forthe diagnosis or treatment of illness or injury”
At present, there is no controlling national coverage policy
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How often can ACP be billed?
Per CPT language, there is no limit
CMS has declined to establish frequency limits at this time
BUT—if billed multiple times, CMS would expect to see “adocumented change in the beneficiary’s health status and/orwishes regarding his or her end-of-life care.”
Where can ACP be billed?
There is no place of service limitation in the CPT codedescriptors
CMS has no place of service limitation in its final rule (80 Fed.Reg. 70956)
ACP codes may be used in any setting, facility or non-facility(although not in the ICU if critical care codes are used)
Who can submit ACP claims?
As per CPT coding convention, 99497-8 may be submitted byany “Physician or other qualified health care professional”
There is no limitation as to physician specialty
Nonphysician practitioners (NPP), e.g. nurse practitioners,physician assistants, etc., may submit ACP claims
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Are there rules governing who may actually perform the service?
Besides the CPT descriptor, there is no introductory languagenor are there explanatory notes governing the performance ofthe service
According to the final rule (80 Fed. Reg. 70956), “99497 and99498 are appropriately provided by physicians or using ateam-based approach provided by physicians, NPPs and otherstaff under the order and medical management of thebeneficiary’s treating physician.”
More on who may perform ACP
CMS expects the billing physician or NPP to “meaningfullycontribute to the provision of the services in addition toproviding a minimum of direct supervision.”
“Incident to” service rules apply
May be of particular relevance in the NH
All applicable state law and scope of practice requirementsmust be met
Must the beneficiary be present?
According to the code descriptor, the service is “face-to-facewith the patient, family member(s) and/or surrogate”
Cannot be reported if performed by phone or via telehealthservices
According to CMS, if beneficiary is not present, must documentthat the beneficiary is impaired and unable to participateeffectively
Must still be face-to-face with family member(s) and/orsurrogate
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Is consent necessary?
Important, because copays and deductibles apply (except inthe case of Annual Wellness Visit)
AWV can technically be done in the NH
ACP services are voluntary
No formal consent is required, but beneficiaries (or familymembers/surrogates) should be given opportunity to declineor receive ACP services, good idea to document
What must be documented?
No requirements in the CPT code descriptor
Consult Medicare Administrative Contractors (MACs)
CMS recommends documentation of:
Voluntary participation (consent)
An account of the discussion
Who was present
Explanation of advance directives, including any completed forms
Time spent in the encounter (definitely include this)
Completed Advance Directive forms arenot, by themselves, sufficient todocument the service for the purposesof reporting the ACP code(s)
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Completion of Advance Directive(s)or other documents (e.g., POLSTParadigm forms) is not necessaryto report ACP services
Can ACP be reported in addition to other services?
May be reported in addition to E/M codes, including all nursingfacility services
But need to keep time separate
May be reported during same service period as TransitionalCare Management or Chronic Care Management
May be reported during global surgical periods
May not be reported on same date as certain critical caseservices, including neonatal and pediatric critical care
Estimating Prognosis
Physicians are notoriously poor at estimating prognosis,usually being overly optimistic
Tools are available to assist Porock index http://eprognosis.ucsf.edu/porock.php Flacker 1 year Long Stay revised index
http://eprognosis.ucsf.edu/flackerlong.php
“Surprise Question” (would you be surprised if yourpatient died in the next 12 months?)
Frailty, failure to thrive, pressure ulcers, delirium carrynegative prognostic implications
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• Illinois recently modified the current IDPHDNR/POLST form to come closer to the nationalPOLST standards used in other states
• POLST stands for “Practitioner Orders for Life-Sustaining Treatment”**
• POLST reduces medical errors by improvingguidance during life-threatening emergencies
IDPH DNR/POLST form …and national POLST standards
** The 2014 version of the form was called“Physician Orders for Life-Sustaining Treatment”
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Evolution of the IDPH DNR Form
“Orange”DNR Form
2013 – POLST Added•The IDPH approved formdeveloped by a statewideconsortium of providers, ethicists,and other stakeholders becomeswidely available.
IDPHUniform DNR“Order Form”
IDPHUniformDNR“Advance
Directive”
POLSTLanguage
Added
Who CanSign Medical
Order isExpanded
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• Promotes quality care throughinformed end-of-life conversationsand shared decision-making
• Concrete Medical Orders that mustbe followed by healthcare providers
• Easily recognized standardized formfor the entire state of Illinois
• Follows patient from care setting tocare setting
Benefits of IDPH DNR/POLST in IllinoisPromoting Patient-Centered Care
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Key Factors Work Together toHelp POLST Work
Color Location Transportability
Organizationsshould assistpersons in
choosing astandardlocation in theirlocal area wherePOLST is kept
Designed tostay with thepatient as the
patient istransported toa new facility
& must behonored in alllocations
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The pink colorhelps the formstand out foreasieridentification.Any color paperis valid; pink ispreferred
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Why Does Illinois Need ThisDocument?
To Insure Accuracy and Continuity ofPatient Wishes Across Care Settings
Ave. of 34 Physician Visits
in last 6 months of life
Ave. of 11 Different Physicians
in last 6 months of life
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Who is IDPH DNR/POLST Designed For?Focusing on patients as partners in their care.
The POLST paradigm is designed for:
Patients facing life-threatening complications, regardless of age;and/or
Patients with advanced serious illness or frailty
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Screening QuestionOne Year is a Rule of Thumb…
• A POLST discussion is appropriate if:
– You would not be surprised if this person diedfrom their illness(es) within the next year
– The patient suffers from a severe illness and hasa preference about the intensity of his/her care
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FIRST PHASE:Complete a PoA. Thinkabout wishes if faced withsevere trauma and/orneurological injury.
NEXT PHASE:Consider if, or how, goalsof care would change ifinterventions resulted inbad outcomes or severecomplications.
LAST PHASE:End-of-Life planning -establish a specific plan ofcare using POLST to guideemergency medicalorders based on goals.
Advance Care Planning Over TimeMaintain and Maximize Health, Choices, and Independence
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The IDPH DNR/POLST Form in Illinois
• 3 Primary Medical Order SectionsA. CPR for Full Arrest
• Yes, Attempt CPR• No, Do Not Attempt CPR (DNR)
B. Orders for Pre-Arrest Emergency• Full Treatment• Selective Treatment• Comfort Focused
C. Medically Administered Nutrition• Acceptable• Trial Period• None
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The IDPH DNR/POLST Form in IllinoisPractitioner Orders for Life-Sustaining Treatment
Cardio-Pulmonary Resuscitation (CPR)
Signature of Attending Practitioner
Medical Interventions
Documentation of Discussion
Reverse Side – Contains More Information and InstructionsR
E
D
C
B
A
AMretidfiicciaallllyy AAddmmiinniisstteerreeddNNuuttrriittiioonn
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• There are multiple kinds of emergencies. This section only addresses a fullarrest event (no pulse and not breathing), and answers “Do we do CPR or not?”
• NOTE! Patients can use this form to say YES to CPR, as well as to refuse CPR.
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Section “A”: Cardio-Pulmonary ResuscitationCode Status – only when pulse AND breathing have stopped
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The IDPH DNR/POLST Form in IllinoisPractitioner Orders for Life-Sustaining Treatment
Cardio-Pulmonary Resuscitation (CPR)
Signature of Attending Practitioner
Medical Interventions
Documentation of Discussion
Reverse Side – Contains More Information and Instructions
AMretidfiicciaallllyy AAddmmiinniisstteerreeddNNuuttrriittiioonn
18
R
E
D
C
B
A
• Three categories explaining the intensity of treatment when the patient hasrequested DNR for full arrest, but is still breathing or has a pulse.
• Full – all indicated treatments are acceptable
• Selective – no aggressive treatments such as mechanical ventilation
• Comfort – patient prefers symptom management and no transfer if possible19 19
Section “B”: Medical InterventionsDo Not Resuscitate does NOT mean Do Nothing
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Section “B”: Medical Interventions
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• Use “Additional Orders” for other treatments that might come into question(such as dialysis, surgery, chemotherapy, blood products, etc.).
• An indication that a patient is willing to accept full treatment should not beinterpreted as forcing health care providers to offer or provide treatmentthat will not provide a reasonable clinical benefit to the patient (would be“futile”).
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Order Reversed2014 form versus 2015 form
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2014 2015
The language was changed to better reflect actual conversations whichgenerally begin with doing everything, before moving to any restrictionsthe patient/family may wish to place on treatments.
• If choosing “Attempt CPR” in Section A, FullTreatment is required in Section B.
– Why? If limited measures fail and the patientprogresses to full arrest, the patient will be intubatedanyway, thus defeating the purpose of markingComfort or Selective.
Section “B”: Medical InterventionsYes to CPR in Section A requires full treatment in SectionB
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Section “A” choices influence medicalinterventions in Section “B”
Yes! Do CPR
DNR: No CPR
Full Treatment
*Requires documentation of a “qualifying condition” ONLY when requested by aSurrogate.
Full Treatmentor
Selective Interventions *or
Comfort Measures *
SectionA Section B
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For Example…
• 85 year-old gentleman admittedfrom home through ED withsevere pneumonia
• The patient is increasingly hypoxicand may be confused
• Patient refuses the vent x3.
• There is a DNR order on the chart.
• The physician feels DNR does notapply to potentially reversibleconditions and begins fullresuscitation.
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POLST ClarifiesUnclear Guidance
• 85 year-old gentleman admittedfrom home through ED withsevere pneumonia
• The patient is increasingly hypoxicand may be confused
• Patient refuses the vent x3.
• There is a DNR order on the chart.
• Comfort only is marked formedical treatment. Intensivesymptom management is startedand resuscitation is not initiated.
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For example…
• A 59 year-old woman beingtreated for breast cancer arrivesat the ED with sepsis.
• In the ICU, she is on oxygen andmaxed-out on pressors.
• She has a DNR order on the chart.
• Staff are concerned they areviolating the patient’s wishes.
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POLST AddressesEthical Concerns
• A 59 year-old woman beingtreated for breast cancer arrivesat the ED with sepsis.
• In the ICU, she is on oxygen andmaxed-out on pressors.
• She has a DNR order on the chart.
• Selective treatment is marked formedical treatment. Staff can feelcomfortable they are honoringthe patient’s wishes.
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For example…
• 67 year-old gentleman presents to EDwith chest pain and SOB.
• He is in pain and confused.
• The cardiologist wants to take him fora cardiac cath and possible stent.
• The patient’s nurse calls the physicianto inform her that the patient has aprior IDPH DNR order on the chart.
• There is confusion whether the patientwould want to be sent for theprocedure anyway.
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POLST Provides Guidancefor Treatment
• 67 year-old gentleman presents to EDwith chest pain and SOB.
• He is in pain and confused.
• The cardiologist wants to take him fora cardiac cath and possible stent.
• The patient’s nurse calls the physicianto inform her that the patient has aprior IDPH DNR order on the chart.
• Full treatment is marked for medicaltreatment and he is immediately sentfor the recommended treatment.
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• Consent needs to be obtained tochange an existing DNR order to fullcode, even during a procedure
• Discuss appropriateness of DNR inlight of procedure and objectives
• If suspended, specify length of time
• Inform procedurists of code status
Don’t Forget DNR for Procedures…Best Practice: DNR Is Not Automatically Lifted
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Creating More Accurate Orders
Some institutions have created orders to better capturethe distinction of these categories, such as DNR-Comfort,DNR-DNI, or DNR-Full Treatment.
Hospitals are NOT required to complete this form whenwriting in-hospital DNR orders for the first time.
Complete a IDPH DNR/POLST form if the patient/legalrepresentative wishes to continue DNR code status orlimit emergency medical interventions after discharge.
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Yes to CPR (28%) No CPR: DNR (72%)
Of 25,000 people in Oregon…
½ of the DNR group
wanted hospitalizationand some level of
treatment for medicalemergencies
½ of the DNR
group wanted onlycomfort measures
for medicalemergencies
JAMA. 2012;307(1):34-35
Full treatment
Limited treatment
Comfort Only
The IDPH DNR/POLST Form in IllinoisPractitioner Orders for Life-Sustaining Treatment
Cardio-Pulmonary Resuscitation (CPR)
Medically Administered Nutrition
Signature of Attending Practitioner
Medical Interventions
Documentation of Discussion
Reverse Side – Contains More Information and InstructionsR
E
D
C
B
A
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Section “C”: Medically Administered Nutrition
• Medically Administered Nutrition 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.
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35
Of 25,000 people in Oregon…
CPR group DNR group
Long-Term feeding tube
Time-limited Trial
No feeding tube
JAMA. 2012;307(1):34-3535
The IDPH DNR/POLST Form in IllinoisPractitioner Orders for Life-Sustaining Treatment
Cardio-Pulmonary Resuscitation (CPR)
Medically Administered Nutrition
Signature of Attending Practitioner
Medical Interventions
Documentation of Discussion
Reverse Side – Contains More Information and InstructionsR
E
D
C
B
A
Section “D”: Documentation of Discussion
• The form can be signed by:• The patient• The agent with a PoA (when the patient does not have decisional capacity)• The designated Healthcare Surrogate
• when the patient does not have decisional capacity and has no PoA orapplicableAdvanceDirective
• a parent of a minor child is a surrogate• a guardian is also a surrogate 37
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1. Patient• Do not move on until patient has been evaluated by the attending
physician who documents the patient lacks decisional capacity andis 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 PoA)• Court-Appointed Guardian• Spouse/ Civil partner• Adult children• Parents• Adult siblings• Grandparents/Grandchildren• Close Friend
Quick Refresher on Decision-Maker PriorityStart at the top and move down the list
Decisional CapacityIt’s not all or nothing.
• Before turning to a PoA or Surrogate, assess anddocument Decisional Capacity.
• The patient may be able to make some decisions evenif s/he can’t make all decisions.
– Patients who are minors should be offered theopportunity to participate in decision-making up to theirlevel of understanding
– Studies consistently show that decisions made by othersare more aggressive and not as accurate as what thepatient would choose for him/herself.
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Section “D”:Documentation of Discussion
• According to IDPH, “one individual, 18 yearsof age or older, must witness the signature ofthe patient or his/her legal representative’sconsent... A witness may include a familymember, friend or health care worker.”
• The witness CAN NOT be the samepractitioner as the one who signs the order.
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Section “D”:Documentation of Discussion
• When the form iscompleted by a personother than the patient, itshould be reviewed withthe patient if the patientregains decisional capacityto ensure that the patientagrees to the provisions.
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Section “D”: Documentation of Discussion
• Adults with an IDPH DNR/POLST are also encouragedto complete a Power of Attorney (PoA).
• Extreme care should be exercised if the PoA orSurrogate wishes to reverse the direction of carepreviously established by the patient
– For example, the patient requested Comfort or SelectiveTreatment, but the PoA or Surrogate wants Full Treatment
– Changes to a form should be based on evidence of thepatient’s wishes
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The IDPH DNR/POLST Form in IllinoisPractitioner Orders for Life-Sustaining Treatment
Cardio-Pulmonary Resuscitation (CPR)
Medically Administered Nutrition
Signature of Attending Practitioner
Medical Interventions
Documentation of Discussion
Reverse Side – Contains More Information and InstructionsR
E
D
C
B
A
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Section “E”: Signature of Practitioner
44 44
• The form can be signed by the (a) attending physician,(b) a licensed resident who has completed at least one yearof training, (c) a physician assistant, or (d) an advancedpractice nurse.
• If more than one person shares primary responsibility forthe treatment and care of the patient, any of those personsmay sign the order.
Requirements for a Valid FormUse White or Pink paper
• Patient name
• Resuscitation orders (Section “A”)
• 3 Signatures
– Patient or legal representative
– Witness
– Practitioner
• All other information is optional
• Pink paper is recommended to enhance visibility, butcolor does not affect validity of form
• Photocopies and faxes ARE acceptable.45
Who Can Assist inPreparing the Form?
Best practice suggests use of those trained in thePOLST Conversation such as (among others):
– Physicians– Social Workers– Nurses– Chaplains– Care Managers– Ethicists– PhysicianAssistants– Advance Practice Nurses
• Find an example of a POLST conversation at:
http://www.uctv.tv/search-details.aspx?showID=18360
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POLST is a Process, Not a FormThe form is a documentation tool.
POLST should not be used as a check-box form, or as areplacement for an informed conversation betweenpatients, families and providers to:
– Identify goals of treatment.
– Make informed choices.
• The conversation should be documented in the medicalrecord, along with a copy of the completed IDPHDNR/POLST form.
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The IDPH DNR/POLST Form in IllinoisPractitioner Orders for Life-Sustaining Treatment
Cardio-Pulmonary Resuscitation (CPR)
Medically Administered Nutrition
Signature of Attending Practitioner
Medical Interventions
Documentation of Discussion
Reverse Side – More Information and InstructionsR
E
D
C
B
A
49 49
Reverse Side: Guidelines and InstructionsCompletion of the form is always voluntary.
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Potential System Concerns
1. Signing practitioner doesn’t have privileges here
– Orders still must be translated into specific institutional orders
– Suggest using “Pt is DNR per IDPH DNR order” and have thatorder signed by assigned staff attending
2. Our physician has never seen this patient before
– Law indicates DNR must be honored in all care settings
– Protected from liability for following an IDPH DNR form in good faith
3. Developing best practices for storing, locating, and transmittingdocument between care settings
– Institutions should standardize where the document is located sothat it is easily available during an emergency, but also protects thepatient’s privacy
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Can I Use POLSTJust as a DNR form?
• Yes - Section A (requesting CPR or DNR) is theonly required section
• Cross out other sections and mark “No decisionsmade”
– If left blank, boxes could be filled in later, effectively creating a medicalorder that the practitioner is unaware of or may not agree with
– Makes it clear that patient did not address the subjects in the othersections – decisions can be made at a later date by creating a new form
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What Should I Do with an OlderIDPH DNR Form?
Continue to follow older IDPH DNR Forms.
Update the older form to the new form when it is feasible.
Review the form with the patient or legal representative
when a change in the patient’s medical condition, goals,
or wishes occurs
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