Please Credit Bud Hammes, Phd Et Al

Please Credit Bud Hammes, PhD et al.

ID# ______

LACROSSE ADVANCE DIRECTIVE STUDY II INSTRUMENT

Eligibility criteria

18 years of ageYesNo

Live in La CrosseCountyYesNo

Die at/under the care of a health care facilityYesNo

Mentally capable 15+ yearsYesNo

Facility / Record reviewed
Long-term care facility patient
□ BethanySt. JosephCareCenter
□ HillviewCareCenter
□ St Joseph Nursing Home
□ Bethany Riverside
□ OnalaskaCareCenter
□ Mulder’s Nursing Home
□ Lakeview Nursing Home / Yes NA
Medical facility
□ Gundersen Lutheran
□ Franciscan Skemp / Yes
Hospice
□ Gundersen Lutheran
□ Franciscan Skemp / Yes NA
Homecare
□ Gundersen Lutheran
□ Franciscan Skemp / Yes NA
Reviewed death certificate / Yes
Request charges / Yes
Data entered / Yes

Description of death:
POLST DATA COLLECTION FORM

1. Location of POLST form

□ None□ Nursing Home□ Hospital□ Homecare/hospice files

2. Orders on the POLST form at time of death.

TREATMENT CATEGORY

CHECK BOX

Written Orders

Date of Order

Resuscitation / DNR/DNAR
Full Code
Medical interventions / Comfort Measures Only/Hospitalize only if comfort measures fail/Supportive Care Only
Limited/Advanced Treatments
Full Treatment/Aggressive Treatment
Antibiotics / No antibiotics
No IM/IV antibiotics
Antibiotics
Artificial Nutrition and Hydration / No artificial nutrition or hydration
Limited trial for _____ days
Artificial nutrition and hydration

3. Who was involved in the development of the POLST?

□ Patient□ Health Care Agent□ Court-appointed Guardian□ Other

ADVANCE DIRECTIVE DATA COLLECTION FORM AT LOCATION OF DEATH

1.Location of Death:

□ Hospital□ Nursing Home□ Home□ Inpatient Hospice□ Other

2. What, if any, advance directive forms are present in the chart? (Check all that apply)

Advance directive/living will (circle type used and indicate date of document)

Power of attorney for health care (POAHC)_____/_____/______Date

Addendum to POAHC_____/_____/______Date

Statement of Treatment Preference form_____/_____/______Date

Wisconsin Statutory POAHC_____/_____/______Date

Wisconsin Declaration to Physicians or

other Living Will _____/_____/______Date

Designated Decision-maker (named by resident)_____/_____/______Date

Legal Guardian _____/_____/______Date

Other (describe) ______/_____/______Date

No form present

3. Was the Power of Attorney activated? □ Yes □ No_____/_____/______Date

(GL CWS/POA form, NH with POA form)

FROM NON-DEATH FACILITY

4. Was an advance directive located at the nursing home (if a hospital death) or at the hospital (if a nursing home or home death?)

□ Yes□ No□ DNADate of this directive _____/_____/______

Continued
5. Document all treatment preferences in the table below. (See advance directive)

Agent authority to admit me to a nursing home or community-based residential facility for the purpose of long-term care:
 Yes
 No / Agent authority to order the withholding or withdrawal of feeding tube and IV hydration:
 Yes
 No
RESUSCITATION (preferences, not orders)
 Check if from dictated note
 I do want cardiac resuscitation
I do not want cardiac resuscitation
I want CPR under certain circumstances as MD recommends
No preference indicated / LOSS OF ABILITY TO RELATE TO SELF, OTHERS AND ENVIRONMENT
I do not want CPR
I do not want antibiotics
I do not want a feeding tube, artificial hydration and nutrition
No preference indicated

PAIN AND SYMPTOM CONTROL IF EFFORTS TO PROLONG LIFE ARE STOPPED

I want to be kept comfortable even if it risks my dying sooner
No preference indicated /

HOSPITALIZATION

 I do want ______
 I do not want ______
 No preference indicated
Goal of Treatment:
 From dictated note
 Prolong Life
 Comfort measures only
IF I AM CLOSE TO DEATH:
I want feeding tubes/artificial nutrition and hydration.
I want tube feedings only as my physician recommends
I do not want feeding tubes/artificial nutrition and hydration
No preference indicated
I want any other life support that may apply
I want life support only as my physician recommends
I want NO life support
No preference indicated / IF I AM PERMANENTLY UNCONSCIOUS/PERISTENT VEGETATIVE STATE:
I want to receive tube feeding
I want tube feeding only as my physician recommends
I do not want tube feeding
No preference indicated
I want any other life support that may apply
I want life support only as my physician recommends.
I want NO life support
No preference indicated

Continued

KIDNEY DIALYSIS

 I do want kidney dialysis
I do not want kidney dialysis
No preference indicated /

VENTILATOR SUPPORT

 I do want ventilator support
I do not want ventilator support
No preference indicated.

ANTIBIOTICS

 I do want antibiotics
 I do not want antibiotics
 No preference indicated
 /

TRANSFUSION

 I do want transfusion
I do not want transfusion
No preference indicated

CHART REVIEW –INTERVENTIONS AT DEATHFOR HOSPITAL DEATHS OR FOR HOSPITALIZATIONS IN THE LAST 30 DAYS OF LIFE --- DATA COLLECTION FORM

1. Use of life-sustaining treatments during the LAST HOSPITALIZATION (within 30 days of death)

Done / TREATMENT PROVIDED / Dates/Times of occurrences
 Yes
 No / Resuscitation (CPR, mouth-to-mouth, electro-cardioversion, etc.): / 1)______
2)______
 Yes
 No / EMSassistance -indicate treatments provided:
1) ______
2) ______/ 1) ______
2) ______
 Yes
 No / Emergency Department Visit without hospitalization-indicate treatments provided:
1) ______
2) ______/ 1) ______
2) ______
 Yes
 No / Hospitalization: / Date of admiss______
Date of disch______
 Yes
 No / Critical Care stay: / Date of admiss______
Date of disch______
 Yes
 No / Surgery: type/description / 1) ______
2) ______
 Yes
 No / Transfusion: / 1) ______
2) ______
 Yes
 No / Intubation: / 1) ______
2) ______
 Yes
 No / Ventilator/Respirator:
Or
 CPAP/BiPAP / Date placed: ______
Date removed: ______
 Yes
 No / Dialysis: (If pt on dialysis prior to 30 days of death, record approx start month/year or # years on dialysis. If pt stops dialysis within 30 days of death, record date ended dialysis.) / Date started: ______
OR ____ yrs
Date ended: ______

Continued

 Yes
 No / Antibiotics: / Date/time started: ______
Date/time ended: ______
 Yes
 No / Non-oral nutritional support (eg. Feeding Tubes or tpn): / Date placed: ______
Date removed: ______

2. Code status order at:

Date / Time
Admission:
At death:

HOSPITAL

□ Full Code

□ PDNR (DNR with comfort measures only)

□ ODNR/DNI – (DNR + limited TX on POLST)

□ ODNR – (DNR + full treatment on POLST)

3.Who made decisions about the patient’s treatment during this hospitalization?

□ Patient□ Health Care Agent□ family (other than health care agent)

□ Court-appointed Guardian□ Other: ______

□ Don’t know who made decisions

4.DATE OF DEATH: ______TIME OF DEATH: ______

CHART REVIEW –INTERVENTIONS AT DEATH FOR NON-HOSPITAL DEATHS --- DATA COLLECTION FORM

Use of life-sustaining treatments during the last 30 days of life:

Done / TREATMENT PROVIDED / Dates/Times of occurrences
 Yes
 No / Resuscitation (CPR, mouth-to-mouth, electro-cardioversion, etc.): / 1)______
2)______
 Yes
 No / Dialysis: (If pt on dialysis prior to 30 days of death, record approx start month/year or # years on dialysis. If pt stops dialysis within 30 days of death, record date ended dialysis.) / Date started: ______
OR ______yrs
Date ended: ______
 Yes
 No / Antibiotics: / Date/time started: ______
Date/time ended: ______
 Yes
 No / Non-oral nutritional support (eg. Feeding Tubes or tpn): / Date placed: ______
Date removed: ______
 Yes
 No / Patient transported to the hospital in the last 30 days of life:
 Admitted to hospital  Admitted to inpatient
hospital
(make sure this/these hospitalization(s) are reviewed) / Date transported/returned ______
Date transported/returned ______

Code status at death/Changes in Code status in the last 30 days:

Date / Time
□ Full Code
□ DNR
□ Full Code
□ DNR
At death:
□ Full Code
□ DNR

Continued

3.Who made decisions about the patient’s treatment during the last 30 days?

□ Patient□ Health Care Agent□ family (other than health care agent)

□ Court-appointed Guardian□ Other: ______

□ Don’t know who made decisions

4.DATE OF DEATH: ______TIME OF DEATH: ______

DEATH CERTIFICATE DATA COLLECTION FORM

1. Zip Code of residence: ______

2. Date of Death:______Date of Birth:______

3. Gender:□ Male□ Female4: Race: □ white□ Black (African American)

□ Hispanic □ Asian (Hmong)

□ Other: ______

4. Marital status:□ married□ widow□ single□ divorced

5. Location of Death:

□ Hospital

□ Gundersen Lutheran

□ Franciscan Skemp

□ Nursing facility

□BethanySt. JosephCareCenter

□ HillviewCareCenter

□ St Joseph Nursing Home

□ Bethany Riverside

□ OnalaskaCareCenter

□ Mulder’s Nursing Home

□ Lakeview Nursing Home

□ Home

□ Other ______

6. Highest grade completed:______

(record total # years)

7. Immediate cause of death:______

______

8. Other significant conditions:______

______

MEDICAL EXPENSES LAST 1 & 6 MONTHS OF LIFE

DATA COLLECTION FORM

ONE MONTH PRIOR TO DEATH  DATE: ______TO ______

SIX MONTHS PRIOR TO DEATH  DATE: ______TO ______

Medicare Part A
Hospital services / Medicare Part B
Clinic services / TOTAL
Last 1 month
Last 6 months