Submitted by Jennifer Hildebrand RN, BS, FCN, Coordinator of Genesis Health Ministry Nurse Program
Capable adults have a right to make their own health care decisions. Advance directive documents such as a living will or durable power of attorney for health can be used to communicate a person’s treatment preferences. Unfortunately, the choices expressed in these documents may not always be available, may not clearly apply to a given situation, and cannot be utilized by non-physicians, e.g., paramedics and first responders.
A number of states, including Iowa and Illinois, are developing and starting to use an advance care planning form known as POLST (Physician Order for Life Sustaining Treatment) or IPOST (Iowa Physician Order for Scope of Treatment). These forms serve in addition to your advance directive. They make it possible for you to provide more detailed guidance about your medical care preferences. Your doctor will talk with you and/or your family for guidance, but the form is generally filled out by a trained individual known as a Facilitator (nurse, chaplain, social worker, parish nurse or health minister, long-term care admissions staff, etc.) after a lengthy discussion is held with those involved. It is then signed by the doctor or, sometimes, a nurse practitioner or physician’s assistant. Once signed by your doctor, this form has the force of any other medical order. These forms are printed on brightly colored card stock so they are easily located in a home or care facility (preferably on the refrigerator door at home or the first page in a medical or hospital record).
The POLST Paradigm Program was developed to improve the quality of patient care and reduce medical errors. It is intended to honor a patient’s choices in all health care settings (emergency care, hospital, clinic, nursing homes, home care, etc.) and to make a patient’s treatment choices known to family members and any care provider.
The IPOST/POLST-QC Community Coalition was formed locally to develop a community plan for training, education, and implementation of these documents. This task will require community collaboration between Unity Point-Trinity and Genesis Hospitals, home care agencies, assisted living, hospice care and extended care facilities, faith communities, emergency services, and physician offices. Within the Quad City region, two forms will be prevalent:
- IPOST-Iowa’s form (salmon colored cardstock)
- Uniform DNR Advance Directive/POLST-Illinois’s form (bright pink cardstock)
There are some minor differences; however, both forms, when completed and signed by appropriate providers as dictated by legislation, are considered a medical order that should be followed across the state. IPOST/ POLST do not replace the advance directive documents such as the living will or durable power of attorney for health care and they are not intended for everyone. These forms are specific for addressing the health care wishes of the:
- Frail and elderly
- Chronically ill
- Critically ill
- Terminally ill
Note: Either form can be completed for minors as well as adults.
Sections A through C of the form list three different medical treatments or services including: resuscitation (CPR-cardiopulmonary resuscitation), medical Interventions (including ventilator use), and artificially administered nutrition (feeding tube and/or intravenous liquids). Section D records the basis for the physician orders.
Each section is thoroughly discussed and the specific wishes of the patient are identified and documented. What sets this document apart from advance directives is the process by which it is completed. The Facilitator, who is trained to work through the sensitive material on the form, assists the patient/family in completing the document.
Some things to consider when completing the form:
- Section A: CPR might restore your heartbeat if your heart stops or is in a life-threatening abnormal rhythm. However, for an older person who is ill, cannot be successfully treated for a condition, and/or may be close to death, CPR is less likely to work. It involves repeatedly pushing on the chest with force, while putting air into the lungs and may cause fractured ribs and/or collapsed lungs due to the force.
- Section B: Medical interventions may include the use of antibiotics and/or ventilators. Certain aspects of care may require hospitalization; sometimes in the intensive care unit. Ventilators are machines that are sometimes needed to help you breathe. They require the use of a tube that is inserted through the throat into the trachea (windpipe) so the machine can force air into the lungs. Placing the tube is called “intubation.” Because the tube is uncomfortable, medicines are used to keep you sedated (unconscious) while on the ventilator. After several days on a ventilator, your doctor may perform a procedure to insert the tube directly into the trachea through a hole in the neck. Generally, people with this type of tube are unable to speak, but it is more comfortable and sedation is not needed.
- Section C: Feeding tubes or intravenous (IV) fluids are sometimes needed to provide nutrition for someone who is unable to eat or drink. These measures can helpful if you are recovering from an illness. However, if you are near death, these measures could actually make you more uncomfortable. Fluids given through an IV can increase the burden on the already affected kidneys or feedings through a tube can cause uncomfortable digestive side effects to a body that is in the natural state of shutting down.
Having a detailed conversation with the patient/family/health care proxy about these issues can help transfer the patient’s wishes onto paper. Once the form is signed by a physician, it becomes a medical order. This document can be revoked at any time and should be updated as the condition of the patient or his/her treatment choices change. The form belongs to the patient!
In the home, the form should be located in an obvious location such as the refrigerator door in a clear plastic sleeve. If the patient is transferred to a facility, the form should accompany the patient and remain on the first page of the medical record. Upon discharge to home or another facility, the form goes with the patient.
Eventually, the goal is to implement an electronic repository of POLST forms. Given the initial success of this model, it is reasonable to believe that the original goal of the advance directives — to ensure respect for patients’ treatment wishes at the end of life — can and will be more completely realized in the future with the addition of the IPOST and Uniform DNR Advance Directive/POLST.
For more information on Facilitator Training or to locate a Facilitator, contact Nancy Phelps, Chair of the Education and Training Committee for the Quad City POLST Coalition. Call 563-421-5829 (office) or email: email@example.com
Certified Facilitators, IPOST and POLST forms can be found at Unity Point-Trinity and Genesis Hospitals and VNA, local nursing homes and extended care facilities, MEDIC Emergency Services and primary care physician offices in the Quad City area.
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