Fine Tuning the POST System: The Case of an Invalid, Contradictory POST Form

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Fine Tuning the POST SystemThe Case of an
Invalid, Contradictory POST Form
Alvin H. Moss, MD, FACP, FAAHPM Center for Health
Ethics and Law
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Objectives
At the conclusion of this conference,
participants should be able to

• Analyze a case which highlights the importance of
  POST form completion
• Describe the most recent evidence on the impact
  of advance directives in the country
• Identify the advantages of the POST system over
  advance directives to honor patients end-of-life
  care wishes
• Explain how the WV e-Directive Registry will
  enable patients end-of-life care wishes to be
  respected
• Discuss common errors on forms submitted to the
  Registry

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Fine Tuning the POST System The Case of an
Invalid, Contradictory POST Form

• A 78 year-old woman was admitted from a
  nursing home with chest pain. She had a past
  history of coronary artery disease status post
  stent placement, congestive heart failure,
  hypertension, lipid disorder, and mild dementia.
  A POST form accompanied the patient and indicated
  CPR in Section A and Limited Additional
  Interventions in Section B. The EMTs and later
  the attending physician wondered what he should
  do with the POST form because Section A and
  Section B seemed to be contradictory. The POST
  form had been prepared by a social worker who had
  signed it, but there was no physician signature
  on it.
• In transporting the patient, EMS worried,
  What do I do if she codes and I do CPR and get
  her back, but she is not breathing normally? Do I
  intubate her? The emergency department physician
  wondered the same thing, but fortunately she did
  not suffer a cardiac arrest during transport
• The attending physician saw the patient
  in the emergency department and reviewed the POST
  form without any additional notes or
  documentation.

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Fine Tuning the POST System The Case of an
Invalid, Contradictory POST Form contd

• When interviewed by the palliative care
  team who was consulted to address the POST form
  inconsistency, the patient indicated that she
  would not want to be kept alive on machines and
  when it was explained to her that if she had CPR
  and lived through it, it was very likely that she
  would end up being on a breathing machine. She
  said, Well then, I dont want CPR. A revised
  POST form was created and signed by the patient
  and the palliative care physician. The patient
  was discharged back to the nursing home.
• The daughter who lived out of state and who was
  the patients Medical Power of Attorney
  representative reviewed the POST form and stated
  she wanted her mother to have CPR.
• What should be done with regard to the
  contradictory POST form and the daughters
  request? How could these situations be prevented
  in the future?

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Learning Issues

• Who should be making the decisions for this
  patient and on what basis?
• How should that person legally be designated?
• How should the POST form be completed and what
  should be indicated in each section?
• What should be done with the POST form after it
  is completed?
• How could the conflict in this case have been
  prevented?

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The Outcomes of Advance Care Planning (ACP)
Latest Studies

• The vast majority (? to over ¾) of older adults
  are willing to participate in ACP
• ACP results in statistically significantly
  different and improved EOLC for patients

Silveira MJ et al. Advance directives and
outcomes of surrogate decision making before
death. N Engl J Med 20103621211-1218. Detering
KM et al. The impact of advance care planning on
end-of-life care in elderly patients randomised
controlled trial. BMJ 2010340c1345.
doi10.1136/bmj.c1345
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Outcomes of Advance Directives

• Of 3746 older adults (gt60 yo), 42.5 required EOL
  decision making
• Of these 1,536 older patients who required EOLC
  decisions, 70.3 lacked capacity
• In short, 29.8 of older adults required EOL
  decisions but lacked capacity
• Of these 999 patients, 67.5 had advance
  directives
• Patients with an advance directive were
  significantly more likely to want limited or
  comfort care and receive it

Silveira MJ et al. Advance directives and
outcomes of surrogate decision making before
death. N Engl J Med 20103621211-1218.
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Elements of the Advance Care Planning Process

• Begins by clarifying the patients current health
  status
• Moves to elicitation of the patients goals of
  care
• Identifies the patients preferred decision-maker
  if the patient loses decision-making capacity
• Completes a Physician Orders for Scope of
  Treatment (POST) form to ensure patients wishes
  are respected

Gillick MR. Reversing the code status of advance
directives? N Engl J Med 20103621239-1240.
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Hickman, SE, et al. A Comparison of Methods to
Communicate Treatment Preferences in Nursing
Facilities Traditional Practices Versus the
Physician Orders for Life-Sustaining Treatment
Program. JAGS. 2010 58 1241-1248.
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(No Transcript)
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Hickman, SE et al. The Consistency Between
Treatments Provided to Nursing Facility Residents
and Orders on the Physician Orders for
Life-Sustaining Treatment Form. JAGS. Published
online 22 Oct 2011
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Elements essential to reliable, high-quality care
for patients with fatal chronic illnessa
systems approach
Lynn, J. et. al. Ann Intern Med 2003138812-818
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Communication across Settings

• the health care facility initiating the
  transfer shall communicate the existence of the
  POST form to the receiving facility prior to the
  transfer. The POST form shall accompany the
  person to the receiving facility and shall remain
  in effect.
• Code of West Virginia, 16-30-1 et seq.

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Components of the System

• Standardized practices and policies
• Trained advance care planning facilitators
• Timely discussions prompted by prognosis
• Clear, specific language on an actionable form
• Bright form easily found among paperwork
• Orders honored throughout the system
• QI activities for continual refinement
• Statewide registry so that forms are available

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Legal Protection with POST Use

• Standardized form according to state law
• Legally recognized DNR identification
• Protection from civil or criminal liability for
  good faith compliance with and reliance upon POST
• Protocol for use in interinstitutional transfers
• Law covers compliance with POST when completed by
  MD not credentialed in facility

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Transfer of POST Form

• Copier to the Photo/Picture setting
• Contrast to the lowest setting
• Double-sided copies on 8 ½ x 11 Astrobrights
  Pulsar Pink 24 lb. paper
• Adjust the contrast setting on your copier to
  achieve the clearest possible copy
• Can copy white FAX onto pink paper

Office Depot, Office Max, Staples
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Form Shall Always Accompany Patient/Resident When
Transferred or Discharged!

On the top of the transfer packet!
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for Palliative Care Evaluation and Advance
Care Planning
The surprise Question A Trigger

• Would I be surprised if this
• patient died in the next year?

Moss et al. Utility of the surprise question to
identify dialysis patients with high mortality.
Clin J Am Soc Nephrol 200831379-1384. Moss et
al. Prognostic significance of the surprise
question in cancer patients. J Palliat Med
201013837-840
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• Accurate, relevant information available in a
  medical crisis
• 24/7 online access by health care providers
  through WVHIN
• Consumer able to confirm online accuracy of their
  advance directives and medical orders (DNR and
  POST forms) in the Registry
• Patients wishes will be respected throughout the
  continuum of health care settings
• Password-protected HIPAA compliant

Registry FAX [phone]
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Total Registry Forms Received by Type
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Problems with POST Completion
Form Type Error Rate
POST Forms 29
Surrogate Selection 27
Living Will 23
DNR Cards 22
Medical Power of Attorney 15
Combined Living Will and Medical Power of Attorney 14

• Just 4 errors make up 72 of all the not
  Registry ready POST forms.

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The Most Common POST Form Errors

1. The Opt-In Box was not initialed
2. The form is missing pages
3. Conflicting elections in sections A and B
4. Physicians signature is missing

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Take-home Messages

• Be sure to initiate advance care planning
  discussions with patients for whom you would not
  be surprised if they died in the next year
• Complete POST forms as part of advance care
  planning
• Submit forms to e-Directive Registry so that
  patients medical orders will be available in a
  crisis

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• Contact the Center for
• ? DNR Cards ? POST Forms ?Brochures
• Advance Directives ? Health Care Surrogate Forms

www.wvendoflife.org 877.209.8086 FAX [phone]