Over the many years of my nursing career, I have learned to acknowledge and appreciate change and I now look at it as an improvement on the past. I firmly believe that a mind set of ongoing learning is the best quality of all caregivers.
In the past, people were reluctant to talk about death, although we realize that death is the final stage of life. All nurses should read Dr. Eleanor
Kubler-Ross’ book on “Death and Dying”. I have been fortunate enough to attend some of her lectures on the subject and I have achieved a much greater understanding and acceptance of death. So in this blog I will discuss End of Life (EOL) Matters.
POLST (Physicians Orders for Life Sustaining Treatment) is an approach to end of life planning. All of the critical elements of EOL care are covered in this form. Completion of this is the responsibility of the Primary Care Physician. (PCP) but usually it is the social worker that introduce EOL information to the Long Term Care (LTC) resident and family as well as schedule an appointment with the PCP. This meeting should be conducted between the resident, loved ones and the PCP. It ensures that seriously ill or frail residents can choose the treatment they want, or do not want and that their wishes are documented and honored.
POLST has been adopted by all but eight States. It gives seriously ill residents more control over their end of life care, including cardio pulmonary resuscitation (CPR), medical treatment and extreme endeavors like ventilation and tube feedings. It must be signed by the resident and physician.
The POLST form is copied on pink paper to ensure the document stands out in a resident’s file. However, copies and faxes in any color paper is considered legal. The POLST form is also accepted by emergency medical response teams.
Advance Directives inform the physician the kind of care, the resident has chosen, should they be unable to make a medical decision for themselves.
An Advanced Directive can include one or all of the following:
Living Will
Durable Power of Attorney (POA) for health care
Do Not Resuscitate (DNR) orders.
A Living Will is a signed and witnessed legal document, describing the kind of medical treatment, or life sustaining measures the person wants if they become seriously or terminally ill.
A Durable POA for health care is a document stating who has been chosen to make health care decisions for the person, if they are unable to do so themselves. This is also a legal document.
A DNR order informs the medical team that the patient does not want to be resuscitated in case of a life terminating medical event. The DNR should be signed by the physician and should be an ongoing part of the monthly Physician’s Order Sheet (POS).
Though it is not required in all states, it may be prudent for the LTC to have in the resident’s file a form covering Health Insurance Portability and Accountability Act (HIPAA ).That way the physician and facility will know to whom they can release information about the resident. It is important that all residents in Long Term Care (LTC) facilities have some end of life determination in place. Should a crises occur, the nurse should know immediately how to respond. There can be legal consequences to inappropriate response to end of life care.
The positive factors for POLST are many. The dignity and desires of the residents are safeguarded. The residents have a voice on how they are treated in a medical crises. The residents can request or refuse certain medical treatments, such as CPR and hospitalization by selecting Comfort Measures Only in a POLST assessment. They can also request limited interventions, or they can choose full treatment which includes all measures to sustain life. As end of life approaches for the resident, family members may have significantly different emotional responses. It is very beneficial that the choice has been verified by the resident.
Long Term Facilities can also use Hospice as a resource to ensure that appropriate EOL care is provided. There must be a signed contract between the LTC facility and the Hospice provider that outlines the roles and responsibilities of each. The resident must be in agreement to receive hospice care. The LTC nurse should notify the hospice of any changes in the resident’s condition. It is also necessary the hospice nurse participates in the care plan documentation.
