1 POST FORM How does this affect me?. 2 Tennessees Health Care Decision Act In 2004, the Health Care Decision Act was passed thus revising Tennessee law.

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POST FORMPOST FORM

How does this affect me?How does this affect me?

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Tennessee’s Health Care Tennessee’s Health Care Decision ActDecision Act

In 2004, the Health Care Decision Act In 2004, the Health Care Decision Act was passed thus revising Tennessee was passed thus revising Tennessee law concerning health care decision law concerning health care decision making.making.

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What does this act do?What does this act do?

Protects patient’s right to make own Protects patient’s right to make own health care decisionshealth care decisions

Promotes Advance DirectivesPromotes Advance Directives Reduces court involvementReduces court involvement Defines legal protection for those Defines legal protection for those

who upholdwho uphold

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Types of Advance DirectivesTypes of Advance Directives

Durable Power of Attorney for Health Durable Power of Attorney for Health Care/Appointment of Health Care Care/Appointment of Health Care AgentAgent

Living Will/Advance Care PlanLiving Will/Advance Care Plan POST form/ Universal DNRPOST form/ Universal DNR

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How POST form came How POST form came about?about?

Tennessee needed one form to address Tennessee needed one form to address DNR and other resuscitative services DNR and other resuscitative services

Tennessee needed one form utilized by Tennessee needed one form utilized by all healthcare entities in the state i.e. all healthcare entities in the state i.e. EMS, Nursing Homes, Hospitals, etc.EMS, Nursing Homes, Hospitals, etc.

Tennessee needed a universal form Tennessee needed a universal form which could travel and be recognized which could travel and be recognized across state linesacross state lines

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Purpose of POSTPurpose of POST

• To provide a mechanism to To provide a mechanism to communicate patients’ preferences communicate patients’ preferences for end-of-life treatment across for end-of-life treatment across treatment settingstreatment settings

• To improve To improve implementationimplementation of of advance care planningadvance care planning

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Basis of POSTBasis of POST

Encourages discussion with patient Encourages discussion with patient and family or surrogate decision and family or surrogate decision

maker of key end-of-life care issuesmaker of key end-of-life care issues

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Impact of Tennessee LawImpact of Tennessee Law

Acknowledged “Universal Do Not Resuscitate Acknowledged “Universal Do Not Resuscitate Order”Order” Means a written order that applies regardless of the Means a written order that applies regardless of the

treatment setting and that is signed by the patient’s treatment setting and that is signed by the patient’s physician which states that in event the patient suffers physician which states that in event the patient suffers cardiac or respiratory arrest, cardiopulmonary cardiac or respiratory arrest, cardiopulmonary resuscitation should not be attempted.resuscitation should not be attempted.

The law also indicated the Board for Licensing Health Care The law also indicated the Board for Licensing Health Care Facilities shall promulgate rules and create forms Facilities shall promulgate rules and create forms regarding procedures for the withholding of resuscitative regarding procedures for the withholding of resuscitative services from patientsservices from patients

T.C.A. 68-11-224 (e), (5) & (i), (1)T.C.A. 68-11-224 (e), (5) & (i), (1)

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What is POST?What is POST?

POST – Physician Orders for Scope of TreatmentPOST – Physician Orders for Scope of Treatment What purpose POST form servesWhat purpose POST form serves

Standardized form containing orders by a physician who has Standardized form containing orders by a physician who has personally examined a patient regarding that patient’s personally examined a patient regarding that patient’s preferences for end of life carepreferences for end of life care

Complements, but does not replace Appointment of Health Complements, but does not replace Appointment of Health Care Agent &/or Living Will/Advance Care PlanCare Agent &/or Living Will/Advance Care Plan

Effective immediately upon order written and when all Effective immediately upon order written and when all requirements metrequirements met

Requirements for valid POST:Requirements for valid POST: Patient’s name and signature (Patient’s name and signature (Patient signature optionalPatient signature optional

according to facility policyaccording to facility policy)) OrdersOrders Physician’s signature (MD/DO)Physician’s signature (MD/DO) Basis for ordersBasis for orders

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POST Form DescriptionPOST Form Description

POST Form formatPOST Form format Top of FormTop of Form

Explanation of formExplanation of form Any section of form not completed indicates full Any section of form not completed indicates full

treatment for that sectiontreatment for that section When need occurs, When need occurs, first first follow orders, follow orders, thenthen

contact physiciancontact physician Patient’s Name/DOBPatient’s Name/DOB

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. CPR: Code or No Code?CPR: Code or No Code? Level of intervention (i.e. comfort measures, Level of intervention (i.e. comfort measures,

limited additional interventions, and full tx)limited additional interventions, and full tx) Comfort care level stipulates: “Not to be Comfort care level stipulates: “Not to be

hospitalized unless comfort interventions in hospitalized unless comfort interventions in the present setting fail” – as applicable to the present setting fail” – as applicable to the facility patient/resident is located inthe facility patient/resident is located in

Use or withholding of antibiotics, IV fluids, Use or withholding of antibiotics, IV fluids, and feeding tubesand feeding tubes

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. Check 1 box each sectionCheck 1 box each section

SECTION ASECTION A: Code Status: Code Status Resuscitate or …Resuscitate or … Do Not Attempt ResuscitateDo Not Attempt Resuscitate

If neither is marked, patient is to be If neither is marked, patient is to be resuscitatedresuscitated

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. Section B:Section B: Medical InterventionsMedical Interventions

Comfort Interventions: Treat with dignity and Comfort Interventions: Treat with dignity and respect. Keep clean, warm, dry. Use medication respect. Keep clean, warm, dry. Use medication by any route, positioning, wound care & other by any route, positioning, wound care & other measures to relieve pain/suffering. Use oxygen, measures to relieve pain/suffering. Use oxygen, suction, manual tx of airway obstruction as needed suction, manual tx of airway obstruction as needed for comfort. Do not transfer to hospital for life for comfort. Do not transfer to hospital for life sustaining tx. Transfer only if comfort needs sustaining tx. Transfer only if comfort needs cannot be met in current location.cannot be met in current location.

Limited additional Interventions: Includes care Limited additional Interventions: Includes care described above. Use medical tx, IV fluids and described above. Use medical tx, IV fluids and cardiac monitoring as indicated. Do not use cardiac monitoring as indicated. Do not use intubation, advanced airway interventions, or intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care.indicated. Avoid intensive care.

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. Full TX:Full TX: All above plus CPR, intubation, All above plus CPR, intubation,

defibrillationdefibrillation Other instructions_______________Other instructions_______________

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. Section C: AntibioticsSection C: Antibiotics

Treatment for new medical conditionsTreatment for new medical conditions No antibioticsNo antibiotics AntibioticsAntibiotics Other instructions____________Other instructions____________

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. Section D: Medically Administered Section D: Medically Administered

Fluids & NutritionFluids & Nutrition No IV fluidsNo IV fluids IV fluids for a defined trial periodIV fluids for a defined trial period IV fluids long termIV fluids long term No feeding tubeNo feeding tube Feeding tube for a defined trial periodFeeding tube for a defined trial period Feeding tube long termFeeding tube long term Other instructions__________Other instructions__________

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. Where does the Physician Sign?Where does the Physician Sign?

Section E:Section E: By a physician who has examined the patient By a physician who has examined the patient

(Mandatory)(Mandatory) Discussed with….Discussed with…. Physician’s printed Name/Phone #Physician’s printed Name/Phone # Basis for OrdersBasis for Orders Patient’s preferencesPatient’s preferences Patient’s best interest (Patient lacks capacity or Patient’s best interest (Patient lacks capacity or

preferences unknown)preferences unknown) Medical indicationsMedical indications Other (specify)Other (specify)

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POST Description cont.POST Description cont.

POST Format cont.POST Format cont. Required Signatures:Required Signatures:

Patient/legal rep, surrogate (Patient/legal rep, surrogate (Patient’s signature isPatient’s signature is optional according to facility policyoptional according to facility policy))

Person preparing formPerson preparing form Title/phone number/dateTitle/phone number/date

Back of Form:Back of Form: Directions for Health Care Professionals:Directions for Health Care Professionals:

Completing POSTCompleting POST Using POSTUsing POST Reviewing POSTReviewing POST

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Who Can Fill Out POST Who Can Fill Out POST Form?Form?

PhysicianPhysician Social Worker – Social Worker – experienced in a health experienced in a health

care settingcare setting NurseNurse

* MD signs regardless who completes MD signs regardless who completes and must discuss form and contents and must discuss form and contents with patient/responsible partywith patient/responsible party

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Need POST if has DNR Need POST if has DNR Order?Order?

POST addresses more than just DNR -POST addresses more than just DNR -Addresses…Addresses…Comfort levelComfort levelIVs/NutritionIVs/NutritionAntibioticsAntibioticsDocuments what individual was involved Documents what individual was involved in discussionin discussionSignature of pt, parent, or guardian or Signature of pt, parent, or guardian or Health Care AgentHealth Care Agent

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POST is for…POST is for…

Seriously ill patients*Seriously ill patients* Terminally ill patientsTerminally ill patients

* * chronic, progressive disease/schronic, progressive disease/s

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Is POST required on all Is POST required on all patients?patients?

NO NO on admissionon admission VoluntaryVoluntary Specifically focuses on medical Specifically focuses on medical

treatment patient does or does not treatment patient does or does not want at want at end of lifeend of life

YES YES on transfer to another health on transfer to another health care facilitycare facility

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What if Patient already has What if Patient already has Advance Directive?Advance Directive?

POST reinforces wishes expressed in POST reinforces wishes expressed in advance directiveadvance directive

POST is a physician’s order that POST is a physician’s order that should be immediately used to direct should be immediately used to direct the care of the patientthe care of the patient

Recommend very ill patients have Recommend very ill patients have both, POST & Advance Directiveboth, POST & Advance Directive

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Need DNR order if have Need DNR order if have POST?POST?

POST serves as the DNR orderPOST serves as the DNR order

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When Should Form be When Should Form be Reviewed?Reviewed?

When patient is transferred from one health care facility to When patient is transferred from one health care facility to anotheranother Facility initiating transfer Facility initiating transfer must must communicate the existence of communicate the existence of

POST form to receiving facility POST form to receiving facility PRIORPRIOR to transfer (POST form to transfer (POST form must accompanymust accompany the patient to the receiving facility) the patient to the receiving facility)

POST orders POST orders remain in effectremain in effect in receiving facility in receiving facility After admission, attending MD should review & a healthcare After admission, attending MD should review & a healthcare

professional should initial POSTprofessional should initial POST If patient’s condition significantly changes, such as:If patient’s condition significantly changes, such as:

Close to deathClose to death Extraordinary sufferingExtraordinary suffering Improved conditionImproved condition Advanced progressive illnessAdvanced progressive illness Permanent unconsciousnessPermanent unconsciousness When patient’s preferences changeWhen patient’s preferences change

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Changing the POST FormChanging the POST Form

Void the form; complete a new oneVoid the form; complete a new one How to Void the POSTHow to Void the POST

Draw a line through the Physician OrdersDraw a line through the Physician Orders Write the word “VOID” in large letters, thenWrite the word “VOID” in large letters, then Sign or initial the formSign or initial the form After voiding the form, a new form may be After voiding the form, a new form may be

completed – leave VOIDED form in permanent completed – leave VOIDED form in permanent recordrecord

If no new form is completed, full treatment & If no new form is completed, full treatment & resuscitation may be providedresuscitation may be provided

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Must Health Care Comply with Must Health Care Comply with POST Form?POST Form?

YESYES Providers can be disciplined by their Providers can be disciplined by their

licensing board for failure to honor licensing board for failure to honor advance directives or decisions of advance directives or decisions of surrogate, provided provider had surrogate, provided provider had actual knowledge of directiveactual knowledge of directive

Law protects good faith compliance Law protects good faith compliance with honoring Advance Directiveswith honoring Advance Directives

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Why POST WorksWhy POST Works

By law MUST accompany patientBy law MUST accompany patient Contains specificsContains specifics It IS a physician’s order – no It IS a physician’s order – no

interpretation is needed and POST interpretation is needed and POST orders are to be followedorders are to be followed

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Take-Home Messages (about Take-Home Messages (about POST Form)POST Form)

POST provides a POST provides a betterbetter means to identify means to identify and and respectrespect patient’s wishes patient’s wishes

POST completions will improve end-of-life POST completions will improve end-of-life care throughout the care throughout the systemsystem

Use of POST will require Use of POST will require communicationcommunication to to make it work in your communitymake it work in your community

““Where’s the POST form?”Where’s the POST form?” www.tennessee.gov/health www.endoflifecaretn.org