new forms, new laws, new thoughts for nurse practitioners canp 2016 anita catlin, dnsc, fnp, faan...

NEW FORMS, NEW LAWS,

NEW THOUGHTS FOR NURSE PRACTITIONERS

CANP 2016

Anita Catlin, DNSc, FNP, FAANEPEC, ELNEC, Resolve through Sharing Certified

10 years on Ethics Committees for American Nurses Association and American College of Obstetricians and

Gynecologists

[email protected]

AGENDA

POLSTDYING WELLPHYSICIAN-ASSISTED DYING

Packages to disseminate for $10.00

POLST in 2016:NPs, PAs and the Impact of AB 637

California POLST Education Program©October 2015 Coalition for Compassionate Care of California 1212Materials made possible by a grant from the California HealthCare Foundation

POLST 2016UPDATE: ChangesUnder AB 637Nurse Practitioners and Physician Assistants Authorized to Sign POLST Forms

What is POLST?

• Physician Orders for Life-Sustaining Treatment (POLST).

• A form that clearly states what level of medical treatment a patient wants toward the end of life.

• Printed on bright pink paper.

• Signed by both a physician and patient (or decisionmaker).

• POLST helps give seriously ill patients morecontrol over their treatment.

California POLST Education Program©October 2015 Coalition for Compassionate Care of CaliforniaMaterials made possible by a grant from the California HealthCare Foundation

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Why POLST?


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1. Patient wishes often are not known.– The Advance Healthcare Directive (AHCD)

may not be accessible.– Wishes may not be clearly defined in

AHCD.– The AHCD is not a physician order.

2. POLST allows patient to express their wishes, and healthcare providers to document and honor patient wishes during serious illness.

Who Would Benefit Most from Having a POLST Form?


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People who: Have chronic, progressive illness Have a serious health condition Are medically frail Anyone who has very strong feelings about the care they

want to receive or not receive (I.e., anyone)

Tool for determination– “Would you be surprised if this patient died within the

next year?”

Where Does POLST Fit In?

Complete a POLST Form

Treatment Wishes Honored

Advance Care Planning ContinuumAge 18

Complete an Advance Directive

Update Advance Directive Periodically

Diagnosed with Serious or Chronic,Progressive Illness (at any age, forms available)


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POLST in California

Effective January 1, 2009California POLST Education Program©October 2015 Coalition for Compassionate Care of CaliforniaMaterials made possible by a grant from the California HealthCare Foundation

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POLST in California


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One form for entire state. Use not mandated. Honoring form is mandated. Provides immunity from civil or criminal liability.

AB 3000, Wolk. Part 4, Sec 7, Probate Code Section 4782

Revising POLST


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The National POLST Paradigm recommends periodically updating the form based on feedback from usage in the field.

Guiding Principle for Revisions: Changes made must provide substantial and significant improvement or clarification to the form.

POLST 2016 Update

ASSEMBLY BILL 637


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AB 637


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California Medical Association (CMA) House of Delegates voted to support this in 2014 after previous opposition.

Assembly Bill 637 was co-sponsored by the California Medical Association and the Coalition for Compassionate Care of California.

Signed by Governor Brown in August 2015.

AB 637


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Authorizes nurse practitioners and physician assistants under the supervision of a physician and within their scope of practice to sign POLST forms.

Law went into effect on January 1, 2016.

2016 POLST Form

2014 POLST Form

2014 & 2016 POLST Form

2014 POLST Form

2016 POLST Form

COMPETENCY

Competency is determined by court of lawUnder the United States Constitution, Americans are given the benefit of the doubt that they are competent, and the burden of proof lies upon the local county to prove to the magistrate that one is not able to make decisions for oneselfThe rights of an individual are very cherished and hard to remove, especially in CaliforniaIn California it is a one year process; with several levels of investigation, chance of success limited

EXAMS FOR COMPETENCEThe Patient Competency Rating Scale (Hart, 2000)

Mini Mental Exam (Folstein, 1975)MacArthur Competence Assessment Tool for

Treatment (Grisso, 1998)Note: Exam may show 100% competence but patient

may have 0% capacity The courts say a competent patient can refuse

treatment even if “neither sensible, rational or well considered, or even for no reason at all” except when patient lacks capacity

CAPACITYA patient with capacity is one who:(a) can hear information, (b) believes the information, and (c) can weigh the information in the balance

and arrive at a choice(d) appreciates the nature of the situation

and appreciates that this applies to him/her (e) goes beyond the individual treatment

decision and to the wider belief system of the patient

Incapacitated patient has a considerable distortion of reality-- A salient belief that is fixed and false and firmly held may be reason to judge as lacking in capacity

COERCION IN TREATMENTUnfortunately, California 5150 Code to detain patient in psychiatric center does not allow for any medical intervention, only psychiatric intervention California Probate Code Section 810-813 lengthy document which delineates legal requires for lack of capacity, which should be based on evidence of a deficit in one or more of the person's mental functions, including a lack of:

Ability to understand and appreciate quantitiesAbility to reason using abstract conceptsAbility to plan, organize, and carry out actions in one's own rational self-interest Ability to reason logically

30California POLST Education Program©October 2015 Coalition for Compassionate Care of CaliforniaMaterials made possible by a grant from the California HealthCare Foundation

Use of POLST with Prior Effective Dates

Best practice is for NPs and PAs to only use the revised POLST form (with the effective date of 01/01/2016)

If NP/PA signs older versions of POLST, it may not be considered valid by local EMS or other providers

2014 POLST Form – Back Side

2016 POLST Form – Back Side

2016 POLST Form

2014 POLST Form

2016 POLST Form

Implementing AB 637


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New law went into effect on January 1, 2016. Physicians, nurse practitioners and physician assistants may sign

POLST under the new law. Best practice is for NPs and PAs to only use the revised POLST

form (with an effective date of 01/1/2016). AB 637 does not alter any other existing regulations, codes, or

standardized procedures and protocols for nurse practitioners and physician assistants in California, including completion of pre- hospital DNR forms.

NPs and PAs are legally authorized to sign POLST forms, regardless of whether the patient has chosen DNR or Attempt Resuscitation/CPR in Section A.

Implementing AB 637


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A new space has been added to the back of the POLST form to write the name of the supervising physician, in compliance with existing regulations.

The actual signature of the supervising physician is notrequired on the form.

The name of the form will remain Physician Orders forLife Sustaining Treatment (POLST)

Physician Assistant: Delegation of Services Agreement


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Written authorization to sign POLST form should be added to the Delegation of Services Agreement (DoSA)

Terminology may include, “(name) PA-C is authorized to discuss with patients or their designated healthcare decisionmaker options for serious illness and sign the POLST form.”

Nurse Practitioner:Nursing Practice Act


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POLST conversations and completion of the POLST form should be included in the Nurse Practitioners Standardized Procedures or Protocols

“Nurse practitioner may hold end of life wishes discussion with patient, document such wishes in charting, and fill out and sign the California POLST document”

There will be more in-depth training in Newport Beach in may, 2016

POLST 2016 Update

THE CONVERSATION


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POLST Conversation


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Introducing the POLST conversation

– To acquaint yourself with patient/family.

– To evaluate patient understanding of his/her health condition.

The POLST Conversation


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POLST is not just a check-box form. The POLST conversation provides context for

patients/families to:– Make informed choices.– Identify goals of treatment.

POLST Conversation- Introduction


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Normalize the conversation:– “We talk about this with everyone.”

– “We want to know what you would want if youbecome seriously ill.”

If questions remain:– “Your doctor, nurse practitioner, or physician assistant

will talk with you.”

POLST Conversation


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– Section A

Use an easily understood medical situation.

– Begin Section A by saying, “If someday you had a heart attack and you died a natural death...”

POLST Conversation


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– Section A

Clarify what CPR means and realistic outcomes. Not like you see on TV Can cause other serious complications Never cures original medical problem Minimal chance of success (survival) in

seriously or chronically ill, frail patients

POLST Conversation


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– CPR and Full Treatment

If “YES, try CPR,” then mark Full Treatment on Section B.– CPR requires Full Treatment, including

ventilator. The primary goal of Full Treatment is

prolonginglife by all medically effective means.

Explore patient’s wish for continued aggressive medical interventions, if they are not getting better.

POLST – Section B Trial Period


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• Full Treatment - What if it’s not working?

• “Trial Period - Not to be kept on life support if notexpected to recover.”

• People ask, “How long is a trial period?” Because we cannot predict a future illness, we do not recommend defining a trial period in advance. The patient’s physician will discuss the situation with patient (if possible) and/or decisionmaker.

Diagram of POLST MedicalInterventions

CPR

Comfort-Focused Treatment

DNRFull Treatment

Selective Treatment


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POLST – Section B Medical Interventions


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For those who choose DNR (Do Not [Attempt] Resuscitation), introduce Section B with the medical situation, “If sometime in the future, you developed a bad pneumonia…”

POLST – Section B Selective Treatment – No Ventilator


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Discuss “Selective Treatment,” with goal of treating “treatable” medical conditions, while avoiding burdensome measures.

Most patients want to go to the hospital for evaluation and treatment.

Corresponds to what many individuals wouldconsider “No Heroics.”

POLST – Section BComfort-Focused Treatment


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Discuss “Comfort-Focused Treatment”, with theprimary goal of maximizing comfort.

“Some people who have advanced illness that cannot be cured choose to focus on treatment which helps keep them comfortable…”

Comfort-focused treatment does not mean “notreatment.”

But generally, no treatment is given with the intent of prolonging life (such as IV fluids for dehydration).

POLST – Section B Selective Treatment for SNF Patients


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Some patients choose to be treated at the SkilledNursing Facility (SNF) where they live.

Discuss option of treatment at the SNF and no transfer for hospitalization. This is important.

For SNF patient requesting treatment at SNF, check box, “Request transfer to hospital only if comfort needs cannot be met...”(e.g., hip fracture).

The “Request transfer” box is ONLY for SNF patients.

POLST – Section C Artificially Administered Nutrition


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Introduce Section C with another medical situation saying, “There is another potential situation to talk about. If you had a stroke…”

POLST Script – Section C


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“If you have trouble swallowing, we can changefood texture and hand feed you.”

“Another alternative is Artificial Nutrition with medically prescribed formula.”

It is important to clarify the benefits and burdensof medically-prescribed artificial nutrition.

Finucane TE, et al. Tube feeding in patients with advanced dementia.

JAMA. 1999; 282:1365-1369.

TALKING TO YOUR SIGNIFICANT OTHERS

• “It is essential that those who love you and/or those who care for you know your wishes”

• “When you appoint a surrogate decision maker, they must agree to honor your wishes”

• Complicated if patient has no appointed representative or has one but has not shared wishes

POLST – Section D Signatures


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The physician, nurse practitioner, or physician assistant who signs the POLST form should review the form with the patient or decisionmaker prior to signing – particularly if they were not present during the initial POLST conversation.

Blank POLST forms should never be pre-signedby the physician, NP, or PA.

POLST – Section D Signatures


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Obtaining signatures: Completing a POLST form is always voluntary. Document the POLST conversation if done via

telephone. Reinforce importance of talking to loved ones.

Who Can Help Complete POLST?


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Healthcare providers – “licensed, certified, or otherwise authorized to provide healthcare in the normal course of business.”

Best practice suggests use of those trained in thePOLST Conversation:– Physicians– Nurse Practitioners, Physician Assistants, Nurses– Social Workers– Chaplains– Social Service Designees

Updating a Patient’s POLST


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Recommendation: Update POLST forms to the 2016 version when reviewing 2009, 2011, or 2014 POLST forms, and anytime there is a change to the patient’s choices or medical condition.

2009, 2011 and 2014 POLST forms will still behonored and valid.

POLST Documentation and Billing


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“More than half of a 25 minute appointment was spent withpatient (and/or decisionmaker) for counseling regarding…”

Office visits include documentation of counseling andtime, stating more than 50% of time spent counseling.

15 min counseling with an established patient = 99213 25 min counseling with an established patient = 99214 40 min counseling with an established patient = 99215

Tools for POLST Conversations


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POLST Script and Cue Cards Diagram of POLST Medical Interventions Helpful Phrases for POLST Conversations POLST Conversation Points: Key Information Cultural and Spiritual Awareness Patient Information Guide

POLST Resources

Consumer Brochures FAQs


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Decision Guides from CCCC

CPR ● Tube Feeding ● Hydration ●Ventilation


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Spanish

© 2015 COALITION FOR COMPASSIONATE CARE OF CALIFORNIA

Chinese Russian Japanese Farsi Vietnamese

Pashto Armenian Hmong Korean Tagalog

… and Braille!

POLST TRAININGPOLST: It Starts with a ConversationFebruary 23-24, 2016

Sharp HospiceCare in San Diego

Register before Jan. 22—save $50!

CCCC Members: $299Non-Members: $349

http://feb2016polst.eventbrite.com

http://feb2016polst.eventbrite.com/

Other upcoming educational opportunities

March 16, 2016, Sacramento

Let’s Talk: Bringing ACP to Your Community

April 7, 2016, SacramentoBuilding Bridges: End-of-Life Care Through a Cultural

Lens

See our website for complete details – www.coalitionccc.org

CoalitionCCC.org/training

http://www.coalitionccc.org/

I I G N I T E . I N S P I R E . I N N O V A T E . I

T A K I N G P A L L I A T IV E C A R E T O T H E N E X T L E V E L

CoalitionCCC.org(916) 489-2222 // [email protected]

mailto:[email protected]

DYING WELL

• Cultural context related to spirituality and pain• With loved ones• In location of choice• Without pain• Without suffering• Using only technology that provides comfort• With affairs (both financial and emotional) in

order• With wishes followed• With plans for aftercare designated

PALLIATIVE CARE

Defined by the World Health Organization “An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

Begins at the same time that curative care begins and continues through illness trajectoryMany ICUs have this as a routine consultation and have brochures throughout unit

PALLIATIVE CARE

• World wide acceptance of dignified and loving end of life care

• Western nations issue of too much health care; Other nations too little care

• Palliative care has been most accepted for older adults, people with cancer

• In the United States, inclusion of failure to thrive, dementias, organ failures

• Palliative care has been less accepted for children and infants

• Palliative care remains unexplored for vulnerable people, such as prisoners, homeless people, and psychiatric patients

HOSPICE CARE

Adults expected to die within 6 monthsCurative efforts often must be stopped

Children have a waiver, may be on hospice longerMay also receive curative efforts

Hospice and Palliative Care work for many/most people, and dying well is anticipated, supported, and obtained

PATIENTS ASKING ASSISTANCE IN DYING• Belgium• Switzerland• The Netherlands• Australia yes/no• Oregon• Washington• Vermont• Montana passed pending• New Mexico passed pending• California Passed October 2015 --working on

implementation laws• Many other states implementing without law

DEATH WITH DIGNITY LAWSCOMPASSION in CHOICES

In none of the States can a nurse legally write an RX for lethal amounts of medication

Nurses must be knowledgable and supportive to patients who ask questions

Can object to participation, but not abandon patient

CONSCIENTIOUS OBJECTION • “For the nurse, conscientious objection may occur when

the nurse interprets that the specific treatment that has been ordered for a patient is harmful or causing suffering. The nurse does not wish to provide this form of therapy and feels sincerely and has felt for some time that this situation warrants a conscientious objection. The nurse objects to the nature of the orders for treatment, willing to assist in other forms of treatment and not wishing to abandon the patient.”

• Catlin, A.J , Armigo, C, Volat, D et al. (2008). Conscientious Objection: A Possible Nursing Response to Care at the End of Life which is Harmful, Causes Suffering, or Torture. Neonatal Network, 2008; 27 (2): 101-6, 107-8.

WHAT IS REQUIREDTwo physicians determine decisionally capable, terminally ill

Two verbal requests separated by 15 day period, Written request

Physician must inform patient of palliative care options, effective pain management, access to hospice care

MD may write RX for lethal amount of medication, nurse may not write

Self administration of prescribed medication is not identified as suicide or assisted suicide

15 YEARS OF DATA FROM OREGON

Vast majority enrolled in hospicePhysical pain is not listed as primary reasonReason is inability to do things that make life worth livingRelatively few patients actually use RXPatients who use are college educated CaucasiansThere has been no “slippery slope” at all

MOST CURRENT WORK

When asked, opens discussionEvery attempt made to palliate pain and sufferingProviding social supportDirect to Compassion in Choices

Many patients stop eating and drinking and this will result in death in about 2 weeks or less

This can be done in the hospital If really suffering, can use terminal sedation

If nurse is unable to morally provide that information, should refer to someone else

new forms, new laws, new thoughts for nurse practitioners canp 2016 anita catlin, dnsc, fnp, faan...

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