IPOST

What You Need to Know

Typical Patient Scenario

• Mrs. G: 90 years old, resides in care facility with multiple co-morbidities: dementia, CHF, COPD• Pneumonia, rushed to hospital• Distraught family arrives• Why aggressive treatment in ICU?• Advance directive, no DNR order

All too Common Story…..

• Very difficult for health care providers to ensure a patient’s treatment choices are communicated and honored from one care setting to another

• Advance planning documents often not useful in emergency situations and lack specificity; many patients receive more aggressive care than desired

• In good faith, professionals provide medical care that may be contrary to the wishes of patient and family

VIDEO

National POLST Movement

IPOST Mission

• To create a system to honor the healthcare treatment choices of individuals through improved communication across the healthcare continuum and to promote community engagement in advanced care planning.

Gap Analysis

• OOH-DNR • Must be terminal• Adults only• Not used in facilities

• Emergency Medical Services• Advance directive not a specific order

• Decision-making inconsistent• Importance of accurate and thorough discussions about goals of care instead of “Do

you want to be resuscitated if your heart stops” without discussion of prognosis, goals, etc.

• Fragmented communication between providers• “Do you want everything done?”

IPOST Fun Facts• Focus group established 2006

• Collaboration St. Luke’s Hospital & Mercy Medical Center in Cedar Rapids

• IPOST officially began in 2008 when included in HF 2539 of Iowa’s Health Care Reform Act

• Piloted in Linn County• Implemented IPOST tool in nursing homes, assisted living, acute care facilities and

hospices

• Highlights of Legislation• 1st POLST pilot in US directed by state legislature• Collaboration with Iowa Department of Public Health and Linn County Public Health• Physician immunity• Physician’s order may cross healthcare settings• Does not require terminal status or have age restrictions

• In 2010, project extended to Jones County• Need for outreach and portability to rural Iowa

IPOST Becomes Law

On March 7, 2012 Governor Terry Branstad signed

IPOST (House File 2165) into Iowa State Law.

***Law went into effect July 1, 2012***

What is IPOST?• 1-page, 2-sided form based on the national POLST movement

• Consolidates and summarizes patient preferences for key life-sustaining treatments including: resuscitation, general scope of treatment in the event of abrupt decline, artificial nutrition

• IPOST complements Advance Directives by translating patient treatment choices into actionable medical orders which can be relied upon across all care settings.

• It is primarily intended to be used by: • an individual with a chronic, critical medical condition in frequent contact with health

care providers or• an individual with a life-limiting illness or• the frail and elderly• Medically appropriate persons under age 18

HIPAA PERMITS DISCLOSURE OF IPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY Iowa Physician Orders

for Scope of Treatment (IPOST) First follow these orders, THEN contact the physician, nurse practitioner or physician’s assistant. This is a medical order sheet based on the person’s current medical condition and treatment preferences. Any section not completed implies full treatment for that section. Everyone shall be treated with dignity and respect.

Last Name

First/Middle Name

Date of Birth

A Check

one CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse AND is not breathing. CPR/Attempt Resuscitation DNR/Do Not Attempt Resuscitation

B

Check one

MEDICAL INTERVENTIONS: Person has a pulse AND/OR is breathing. COMFORT MEASURES ONLY Use medication by any route, positioning, wound care and

other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in current location.

LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical treatment, cardiac monitor, oral/IV fluids and medications as indicated. Do not use intubation, or mechanical ventilation. May consider less invasive airway support (BiPAP, CPAP). May use vasopressors. Transfer to hospital if indicated, may include critical care.

FULL TREATMENT Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation and cardioversion as indicated. Transfer to hospital if indicated. Includes critical care.

Additional Orders: ________________________________________________________

C

Check one

ARTIFICIALLY ADMINISTERED NUTRITION Always offer food by mouth if feasible. No artificial nutrition by tube.

Defined trial period of artificial nutrition by tube.

Long-term artificial nutrition by tube.

D MEDICAL DECISION MAKING Directed by: (listed in order of Iowa Code/Statute for Priority of Surrogates; check only one)

Patient

Durable Power of Attorney for Health Care Spouse

Majority of Adult Children

Parents

Majority rule for nearest relative

Other: ____________________________

Rationale for these orders: (check all that apply)

Advance Directives

Patient’s known preference

Limited treatment options

Poor prognosis

Other: ________________________

Physician/ARNP/PA signature (mandatory)

Print Physician/ARNP/PA Name

Date

Phone Number

Patient/Resident or Legal Surrogate for Health Care Signature as identified above (mandatory)

Date

SEND IPOST WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

DOCUMENT THAT IPOST FORM WAS TRANSFERRED WITH PERSON

Use of original form is strongly encouraged. Photocopies and Faxes of signed IPOST forms are legal and valid HIPAA PERMITS DISCLOSURE OF IPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

Information for Person named on this Form Person’s Name (print) _______________________________

This form records your preferences for life-sustaining treatment in your current state of health. It can be reviewed and updated by your health care professional at any time if your preferences change. If you are unable to make your own health care decisions, the orders should reflect your treatment preferences as best understood by your surrogate.

Contact Information Surrogate (optional)

Relationship Phone Number

Directions For Health Care Professionals

Completing IPOST Must be completed by a health care professional based on patient treatment preferences and medical

indications. IPOST must be signed by a physician, nurse practitioner or physician’s assistant to be valid. Verbal

orders are acceptable with follow-up signature by physician, nurse practitioner or physician’s assistant in accordance with facility/community policy.

Use of original form is strongly encouraged. Photocopies and FAXes of signed IPOST forms are legal and valid.

Using IPOST Any section of the IPOST not completed implies full treatment for that section. A semi-automatic external defibrillator (AED) should not be used on a person who has chosen “Do Not

Attempt Resuscitation” unless otherwise specified. Deactivation of internal defibrillators if comfort measures only are in effect. Medications by alternative routes of administration to enhance comfort may be appropriate for a person

who has chosen “Comfort Measures Only.” Voiding IPOST

A person with capacity, or the valid surrogate of a person without capacity, can void the form and request alternative treatment.

To void this form, draw line through sections A through C and write “VOID” in large letters across the form and sign and date that line if IPOST is replaced or becomes invalid.

Any changes require a new IPOST. Transferring/Discharging with IPOST

The IPOST form belongs to the person. The IPOST form MUST accompany the person upon all transfers between care settings. Document that the IPOST was sent with the person. Recommended use at home: Advise patient they must keep IPOST in easily accessible location that the

ambulance service could find if no family or friends present (example may be in an envelope or baggie on the refrigerator).

Reviewing IPOST This IPOST should be reviewed periodically whenever:

1. The person is transferred from one care setting or care level to another, or 2. There is a substantial change in the person’s health status, or 3. The person’s treatment preferences change.

Reviewed by: Date: Reviewed by: Date: Reviewed by: Date:

Who implements IPOST?• Ideally a certified facilitator leads goals of care

conversation (usually 30 mins-1 hour)

• Physician, PA, or APRN may hold the conversation and validate and sign the form

• The critical factor in the above is to maintain the integrity of the process, ensuring the conversation is as thorough as necessary

Community StrategyThe goal is a standardized, systematic model that can be implemented in many ways yet maintain integrity of process.

• Identify Champion• Establish Community Coalition• Train those having conversations• Educate healthcare providers• Establish operational processes• Evaluate

Champion and Coalition

• Identify Champion(s) • At least one but could be several people• Consider one administrative type champion • Consider one physician champion

• Establish Community Coalition• Identify key stakeholders for inclusive community membership• Suggestions: Physicians/ARNP/PA’s, hospitals (admin, ED, palliative care,

social work), EMS home care, faith community, hospice, long term care, residential and assisted living, ethicist, legal, public health, community member

• Champions should participate on coalition• Coalition drives the operations, education and provides oversight

Training and Education

• Respecting Choices- POLST education• An informed decision• Gold standard

• Train the Trainer Model• Certified facilitators• Certified instructors

• Education to the providers, institutions and community

Operations and Evaluation

• IPOST at front of patients medical chart if in a facility• Must translate orders from IPOST into your medical record;

do not use copy• IPOST transfers with patient from one healthcare setting to

another including to and from home• Update or void IPOST when the patient’s treatment choices

change or substantial change in person’s health status• Regular review of IPOST at quarterly care conferences in

facilities or physician appointments• Data collection to determine implementation rate and

effectiveness

IT’S WORKING!Effecting culture change by honoring a person’s healthcare treatment choices

Pilot Project: Medical Chart Review• Number of IPOSTs completed: 1,306 total

• Randomized chart review completed summer 2011• Medical charts reviewed in nursing facilities and hospitals

• Medical record reviews • 62 Linn County• 67 Jones County

• Living Wills• 45% of patients completing IPOST had Living Will in medical chart• 100% consistency between Living Will and IPOST wishes

• Treatment provided consistent with IPOST (N=31)• 100% consistency between IPOST choices and treatment

provided when transferred to acute care

Results• DNR patients (N=107): 58% of patients reflected preferences for life-

prolonging treatment in at least one other category

• Resuscitate patients (N=18): 88% of patients reflected preferences for life-limiting treatment in at least one other category

• We found that healthcare providers make treatment decisions based on the patient’s resuscitation status

• Based on treatment preferences indicated in the IPOST medical chart review…this would result in 62% of the patients receiving treatments that they would not have preferred

Healthcare Provider Survey

Was treatment altered to respect patient choices based on having an IPOST available?

• 28% (n=16) surveyed indicated IPOST form altered treatment

• Most frequent treatment altered was Comfort Measures Only.• 33% indicated treatment would have been more aggressive without IPOST

• Second most frequent treatment altered was Type of Resuscitation• 22% indicated CPR/Attempted Resuscitation was due to presence of IPOST

• No intubation (19%). No Intravenous Line started (15%), and increased Level of Treatment (11%) were also indicated by those surveyed that these treatments were altered based on the IPOST

Healthcare Provider Survey

What do healthcare providers think about IPOST?• 90% wished more patients in the area had IPOST forms, the other 10% were

neutral

• 92% agreed that the IPOST form provides clear instructions about patient’s preferences

• 87% feel more comfortable knowing what to do when an IPOST form is available

• 80% agreed that the IPOST form has made more difficult decisions easier

Next Steps• Multiple state organizations have come together to provide

education, administrative structure and to develop strategy for statewide implementation. The Iowa Healthcare Collaborative (IHC), led by Dr. Tom Evans, will coordinate the strategy.

• The Iowa Department of Public Health (IDPH), under the new legislative language, will prescribe the uniform IPOST form and direct availability of the form.

• Also joining this collaborative effort is the Iowa Hospital Association, Iowa Health System, Iowa Healthcare Association, Iowa EMS Association, and Hospice and Palliative Care Association of Iowa.

• IDPH has information posted on their website (www.idph.state.ia.us) . IHC has developed a tool kit which is available on their website (www.ihconline.org) .

Next Steps (cont.)• If your community is interested in implementing IPOST,

your first step is to identify IPOST Champions and to create a Community Coalition involving key stakeholders. These may include physicians/ARNP/PA’s, hospital personnel (administration, ED, social work), palliative care programs, EMS, home care, faith communities, hospice, long-term care, residential and assisted living, an ethicist, legal, public health and community member.

• Additional information will be forthcoming to assist you in development of the community strategy. In the meantime, contact the Iowa Healthcare Collaborative at meyerr@ihconline.org for more information.

IPOST PROCESS Nursing Facility

Overview

-IPOST form belongs to the patient. -IPOST form is valid as a medical order statewide regardless of where the patient resides. -IPOST is appropriate for an individual who is frail and elderly, or who has a chronic, critical - medical condition or terminal illness.

Use of form

-First paper on facility chart, kept in clear sleeve with return to sender sticker. -IPOST remains in chart until resident transfers health care settings (may take IPOST with resident during outings if appropriate). -Facility MUST ensure form is sent with resident upon transfer/discharge. -No copies for permanent medical record! -Facility may make copy of IPOST prior to transfer to hospital to be kept in case IPOST is lost. Upon resident’s return to facility; copy must be DESTROYED. -If patient is taking IPOST home, advise patient they must keep IPOST in easily accessible location that the ambulance service could find if no family or friends present (example may be in an envelope or baggie on the refrigerator). -Do not label or sticker form. -Section C of form addresses nutrition by tube only; not IV (i.e. TPN). -The IPOST form should be reviewed periodically and a new IPOST form completed when the patient/resident’s treatment preferences change. Review may also occur when the person is transferred from one care setting or care level to another. -If patient dies; form should be kept with medical record. -Revoking the IPOST document at a care facility occurs through the destruction of the document at the facility where the person resides. A new IPOST document may then be completed with updated treatment choices. -If IPOST is changed or revoked at an inpatient status; the process will be -To void the IPOST form: draw a line through sections A through C and with “VOID” in large letters across the form and sign and date that line if IPOST is replaced or becomes invalid and put back in plastic sleeve.

-A new IPOST document may then be completed with updated treatment preferences and placed in the plastic sleeve.

-This process will enhance communication and eliminate confusion when changes regarding treatment preferences are made.

Documentation

-Must document, upon resident’s return/admission to facility, that patient returned/arrived with IPOST form. -IPOST form is not to be used as the only orders as it is not a part of the permanent record; it provides guidance to write orders in your record. -Orders must be written in the record to reflect the treatment wishes of the patient based on the IPOST form. -If surrogate decision maker unable to be present to sign, fax form for signature and then mail out original and have them return to your facility, -If patient has Advance Directive that is known to be in conflict with IPOST form, AD takes precedence. -If an IPOST is initiated during the facility stay:

-Trained facilitator completes form; inquire whether physician/ARNP/PA requests appointment -with pt/surrogate to discuss.

-If patient has Guardian as surrogate decision maker, write this in under Other -Physician/ARNP/PA sign (telephone orders are acceptable with follow-up signature per policy) -Document form was initiated

Copies/Faxes

-Copies/faxes of signed IPOST forms are legal and valid; HOWEVER our process does NOT recommend copies under most circumstances. -A copy/fax may be valid only if original form was not sent with patient. If inpatient facility validates with receiving facility that copy/fax is the most recent for a patient, it may be used. An example: if patient transfers from facility to Emergency Department and IPOST did not arrive with patient; ED may accept fax of IPOST after validation with facility it is most recent version. Use of original form is strongly encouraged! -Documentation in the medical record must reflect this has occurred.

Obtaining IPOST Form

In Summary• IPOST may be used throughout the state of Iowa beginning

July 1, 2012

• To implement IPOST in your community, it is suggested that a local Coalition be formed to develop a community strategy

• Best Practice is to pursue a facilitated train the trainer model for facilitator education (those having conversations with patient/family)

• Patient treatment choices are honored across healthcare settings with IPOST.

References• https://www.legis.iowa.gov/index.aspx; Bill Quick Search

HF2165• http://www.ohsu.edu/polst/

Resources• IHC tool kit

• (go to top of page under toolkits tab): http://www.ihconline.org/ • Web Cast

• http://iha.mediasite.com/mediasite/Play/16a5aec5994c406ca2ea94a1a80752a91d

• IDPH • http://www.idph.state.ia.us/ipost/default.aspx

Stephanie Anderson,MSN, RN, CHPNDirector, Palliative Care, Hospice & Home CareIPOST Pilot Co-ChairSt. Luke’s Hospital, Cedar Rapids, Iowaanderssc@crstlukes.com

Pat Giorgio, MPSPresident/CEO of Evergreen EstatesCedar Rapids, Iowapat@evergreenestates.biz

ContactsChristine Harlander, RN, BSN, CHPNPalliative Care Specialist IPOST Pilot Co-ChairMercy Medical Center, Cedar Rapids, Iowacharlander@mercycare.org

Jean Westerbeck, R.N., NHAAdministratorLiving Center WestCedar Rapids, Iowa 52403319-366-8714westerbeckjean@yahoo.com