Patient Is Currently Living at Home

Patient is Currently Living at Home

Primary Care TeamMemberKey Points:Completing a newPOLST Roleof Decisionmaker

You willbeplayingtheroleofthePrimary Care Team Member (Physician, Nurse Practitioner, Physician Assistant, Office Nurse, or Care Manager). During the roleplayyou willbespeakingwithapatientandhisson regardingdeveloping a POLST. A fourthperson maybeanobserver(providingfeedbackattheend,plustimekeeper).

Background:ThepatientisMr. Charles Franklin,DOB 1-5-1934. He livesin his own home and his son lives next door. Hismedicalproblemsincludeahistoryof heart failure with an ejection fraction of 30%,aortic stenosis,hypertension, andosteoarthritis. He iscompetentto makehisown decisions. He is currently receiving home health care following a hospital admission for exacerbation of this heart failure. His primary care provider (PCP)justgavehimtheresultsof his echocardiogram which showed hemodynamically significant aortic stenosis.Mr. Franklin was evaluated by his cardiologist who reviewed all options. Mr. Franklin has refused any further cardiac interventions. The PCP requested acareplanconference todiscuss completing a POLST in light of Mr. Franklin’s current cardiac status.

Primary Care Team Member:Use POLST Scriptor CueCard to completeanew POLST form.

1. Introduce yourself and any other team members. Tell Mr. Franklin you will be talking to him about a POLST form. “Dr. Brownaskedus totalk to you aboutyour treatment wishes. We have a form, called a POLST, that we complete to show what care you would like and it will be available to any of your care providers. This issomething we do for most of our patients.

How are you doing, Mr Franklin? I know you recently had an echocardiogram.” Mr. Franklin states the test shows his heart condition is not improving.

2. POLSTSectionA:ExplainSectionA usingtheCueCardanddocumentMr. Franklin’s choice.

IfpatientchoosesAttemptCPR, thenFullTreatmentisrequiredfor SectionB.

3. POLSTSectionB:Introduce and explainSectionB. In discussing his goals for care, Mr. Franklin states, “I want to stay at home. I don’t want to be hospitalized. I would like to die in peace at my own home”. Various options for full or limited treatment as well as comfort care should be discussed

If Mr. Franklinchooses FullTreatment,besure todiscuss ifhe wants long-termventilatorifhe werenotimproving(perCueCard).

Note:PatientcanchooseDo Not AttemptCPRandFullTreatment(SectionB). Ask Mr. Franklin, “Whatchoicemakes sense foryou?” anddocumenton thePOLST form.

4. POLST Section C: Explain choices for use of antibiotics.

5. POLSTSectionD:ExplainSectionD. Patientsays, “Notubefeeding”thenasks aquestion aboutfeelinghungry andpossible“starvation.”

(More detailsarefound inPOLST ConversationPoints– AdditionalInformation,including“loss ofappetiteisnormalas onenearsdeath.During thedyingprocess, thebody cannot

metabolizeandusefluids.Peopledo notfeelhungry. During thistime,forcingfluidsthroughartificiallyadministerednutritionoftencausesmoresufferingby increasingswelling,fluidretentionandfluidinthelungs.Deathisduetothedisease,not starvationor lackof fluids.”)

Ask Mr. Franklin whathischoiceisfor Section D.Documenthischoice. Mr.Franklin asks, “Can I changemy POLST?” You respond,“Yes, if you ever change your mind we‘void’theoldPOLST and a newPOLST can becompleted.

6. Encouragecompletionof Advance HealthCareDirective.Describetheimportanceof the AHCD tonamehisagent/decision makerifinfuturehe cannotmakehisown decisions,andthe importanceof consistencybetweentheAHCD andPOLST. Mr. Franklin shows his recently completed ACHD which names his son as his agent.

7. Reviewpatient’schoices.Discuss signature requirementsandhavepatientsignform.If patient or familyhavequestionsyou couldnotanswer, referfor additionaldiscussionwithhisPCP.If needed,developandfacilitateafollow-up plan for further conversation.

Note: If Mr. Franklin’s choice would be “Comfort Measures Only”, and he wishes is to remain at home an “Out of Hospital DNR Order” can be discussed

11/20/14

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PatientKeyPoints: Completing a newPOLST,Roleof Decisionmaker

You willbeplayingtheroleof thepatient.During theroleplayyou willbethepatient speakingwithaprimary care team member (Physician, Nurse Practitioner, Physician Assistant, Office Nurse, or Care Manager) andyour sontodiscusscompleting aPOLSTgivenyour recent hospital admission and current status.A fourthperson maybean observer(providingfeedbackattheend,plustimekeeper).

Background:You are Mr. Charles Franklin,DOB 1-5-1934. You livein your own home and your son lives next door to you.Yourmedicalproblemsincludeahistoryof heart failure with an ejection fraction of 30%,aortic stenosis, hypertension, and osteoarthritis. You are competentto makeyourown decisions. You are currently receiving home health care following a hospital admission.

Your primary care provider (PCP)justgaveyoutheresultsof your echocardiogram which showed significant aortic stenosis.The PCP requested acareplanconference todiscuss completing a POLST in light of your current cardiac status.

Patient: The primary care team memberwillrevieweachsectionof the POLST. Your choicesarebelow.

1. POLSTSectionA:CardiopulmonaryResuscitation.Afterthe primary care team member reviews,yousay, “I don’t want any of those machines to keep me alive. Iwanttobea Do Not AttemptResuscitation.”

2. POLSTSectionB,Medical Interventions.Afterthe primary care team memberdiscussion,you say,“I wanttohaveLimitedInterventions. I don’t want machines, but if my heart acts up again, I want to be treated at homeif I can be. I really do not wanttogo backtothehospital if I can help it.”

3. Your sonasks, “Dad,whydon’tyou wanttogo tothehospital?”You tellyour son “No morehospitals! Thehome health staff knows whatI likeand whatI don’tand I wanttobecomfortable.”

The primary care team member talkswithyour sontoo,asyourson isupsetandquestioningyour decision.

4. After reviewing the POLST Section C, Antibiotics, you decide that your primary care provider and you or your son can determine the use of antibiotics at a time you may have an infection.

5. Next you review POLSTSection D, No ArtificialNutrition,includingFeedingTubes.You tellthe Primary Care Team Member,“I do notwanttubefeeding.s”

6. Your completed POLST is signed and dated.Itwillbe filedinthechart after your primary care provider has signed it and a copy should be kept by you at home.

Materials adapted and used with permission from the Coalition for Compassionate Care of California,

2/12/14

SonKeyPoints: Completing a newPOLST,Roleof Decisionmaker

You willbeplayingtheroleof thepatient’sson.During theroleplayyou willbespeakingwithaprimary care team member (Physician, Nurse Practitioner, Physician Assistant, Office Nurse, or Care Manager) andyour fatherto discuss completing aPOLSTgivenhisnew prognosis.A fourthperson may beanobserver(providingfeedbackattheend,plustimekeeper).

Background:Thepatientisyour father Mr. Charles Franklin,DOB 1-5-1934. He livesin his own home next door to you.Hismedicalproblemsincludeahistoryof heart failure with an ejection fraction of 30%,aortic stenosis, hypertension, and osteoarthritis.He iscompetenttomakehisown decisions. He is currently receiving home health care following a hospital admission to treat his heart failure. You arehisagenton theAHCD. His primary care provider (PCP)justgavehimtheresultsof his echocardiogram which showed significant aortic stenosis.The PCP requested acareplanconference todiscuss completing a POLST in light of your father’s current status.

Son:The primary care team memberwillrevieweachsectionof POLSTandyour mother’schoicesarebelow:

1. POLSTSectionA:CardiopulmonaryResuscitation.Afterthe primary care team member reviews,your fathersays, “Iwanttobea Do Not AttemptResuscitation.”

2. POLSTSectionB,Medical Interventions.Afterdiscussion with the primary care team member,your father states,“I wanttohaveLimitedInterventions.”He says emphatically,“It’s OK totreatmeat home, butI do NOT wanttogo backtothehospital.”

3. You would likeyour fathertogo tothehospitalifneeded. You areupsetandask, “Dad whydon’tyouwanttogo tothehospital?”

Yourfatherresponds,“Nomore hospitals!The home health care staffknows whatI likeand whatIdon’tand I wanttobecomfortable.”

Theprimary care team membertalkswithyou too.Aftertheteam member speaks,you thensay, “Dad,IthinkI understand now.”

4. After reviewing the POLST Section C, Antibiotics; your father decide that he, his primary care provider and you can determine the use of antibiotics at a time he may have an infection.

5. Next you review POLSTSection D, No ArtificialNutrition,includingFeedingTubes.Your father tellsthe primary care team member, that he does notwanttubefeeding.

6. Your father’s completed POLST is signed and dated.Itwillbe filedinthechart after his primary care provider has signed it and a copy will be kept in his home.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 2/12/14

ObserverandTimekeeperKeyPoints: Completinga new POLST,Roleof Decisionmaker

You willbewatchingaroleplaybetweenthe primary care team member, apatientandhisson.Whenthey havereviewedtheirroles(4 to5 minutes),theroleplaywillbegin.At theendof 10 to12 minutes,stoptheroleplay.As theObserver, you willprovidefeedback,as outlinedbelow. Pleasemakenoteof particularthingsthatyou feltwerehelpfulby theprimary care team member.

1. Keeptrackof time.Stoproleplayafter10to12 minutes,eveniftheyarenotfinished.

2. Writedown keywords or pointscoveredthatwerehelpful.

3. Notedetailswhereyou would offersuggestionsforimprovement.

4. Spend about5 minutesattheendof theroleplay,askinghow eachperson felttheroleplaywentandofferyour feedback,bothpositiveandnegativetoimprove.

Background:ThepatientisMr. Charles Franklin,DOB 1-5-1934. He livesin his own home his son lives next door.Hismedicalproblemsincludeahistoryof heart failure with an ejection fraction of 30%,aortic stenosis, hypertension, and osteoarthritis.He iscompetentto makehisown decisions. He is currently receiving home health care.

His primary care provider (PCP)justgavehimtheresultsof his echocardiogram which showed hemodynamically significant aortic stenosis.The PCP requested acareplanconference todiscuss completing a POLST in light of Mr. Franklin’s worsening cardiac status.

Keyareasto observe:

A. Participantsintroducedthemselves.

B.The primary care team memberprovidedareview of thePOLST, preparingthepatienttocompletea POLST ifhe wished.

C.The primary care team memberfocusedon the son’sconcerns,butclarifiedthathisfatheriscapableof makinghisown decisions.

D. Follow-upplanwas developedifappropriate.

Materials adapted and used with permission from the Coalition for Compassionate Care of California, 2/12/14