In 2008, I attended the UCLA LMG (Leadership and Management in Geriatrics) course that has continued under the leadership of CALTCM.  I was paired with a nursing professor at Sacramento State who was quite helpful as a mentor for my project which was the implementation of the new POLST Form in Sonoma County.  I teamed with Susan Keller, who energetically partnered with many people and provided detailed trainings in many settings of care. Sadly, despite our efforts, I still find POLST forms initiated by frontline SNF admitting nurses that don’t have choices congruent with the ones I find on my assessments.  In addition, many of the forms fail to record basic information like care contacts, presence of AHCDs/DPOAs, and who assisted with completion of the form.  

This summer, as a part of vacation coverage for another physician, I discovered a systemic problem I had not seen before.  In this facility, key physicians have a binder where nurses place return lab, POLST forms they’ve initiated, and change of condition notification SBARs, which are then reviewed by that physician on a daily basis M-F.  In the folder I saw a POLST Form for my review and signature that only checked Attempt CPR (ACPR) in a 95 y/o woman and had no other information on the form apart from the patient’s signature. I reviewed the chart and saw that the physician had a template macro in his H&P documenting an advance care planning discussion as the basis for the POLST form decisions, but no further details about the patient’s thinking, and no completed POLST form.  After further investigation, I discovered that this facility had been asked by the Kaiser team to have nurses initiate a POLST by transposing the CPR status on the incoming orders from the acute hospital for physicians to sign. In turn this directive had been applied to all facility admissions.  

This policy ignores the fact that the triggers for CPR and the outcomes for CPR are very different in the well-resourced and well-staffed acute care hospital setting than in the SNF setting, where it is almost always triggered when someone is found actively dying and becomes a paramedic run.  In my work with patients of advanced age who have chosen “attempt CPR” in the acute hospital, they still rarely choose ACPR in the SNF setting, once they understand our dismal outcomes for CPR initiated in someone actively dying. 

In addition, I commonly see patients in their last years of life who already have a DNAR (Do Not Attempt Resuscitation) on their outpatient POLST, which temporarily becomes ACPR in the acute hospital setting, and then reverts to DNAR on discharge to a lower setting of care.  If these preferences were not discovered on admission and the hospital ACPR continued in the SNF, the facility would be risking a wrongful resuscitation lawsuit, which in fact are occurring. And worse than that, they would be performing an unwanted and futile act of violence on a frail elder patient, potentially causing severe pain and suffering and prolonging the dying process.

I fear that some facilities and clinicians are viewing the CPR decision as a quick task rather than an opportunity for a meaningful and diligent advance care planning conversation that helps them plan for the kind of care their patient wants and minimizes the risk of providing care that they don’t want.  In addition, if the only concern is for CPR status, a PIT Form (Preferred Intensity of Treatment) form is the correct form to use since other providers will then know that a professional advance care planning conversation likely didn’t happen and doesn’t have the effect of a physician order. In addition, a PIT form is the preferred form in persons who are not near the end of their life, where the outcomes of ACPR are much better and the decisions for that admission are not potentially carried far forward into the future when they may be near the end of life.  

One other summer discovery of an “Integrity” issue occurred when I provided vacation coverage at another facility.  I was asked to sign a nurse-initiated POLST form for a patient I was admitting that had discordant (and invalid) choices of ACPR in section A and Selective Care in Section B.  I had the nurse read the qualifier in Section A in parenthesis after the initial “Attempt Resuscitation/CPR” (Selecting CPR in Section A requires selecting Full Treatment in Section B). She told me that their former medical director had viewed the choices in section B as independent of Section A, which is clearly and emphatically not the case.  The Emergency Medical Services Authority (EMSA) system works by well-defined protocols. In the unlikely event circulation is restored during ACPR, Full Intensity Treatment (full care) will be provided in the acute hospital setting regardless of misguided POLST choices for Selective or Comfort-Focused care.  If your facility and providers need more training on the POLST, this is readily available on an ongoing basis through the Coalition for Compassionate Care of California and can be found on their website at: https://coalitionccc.org/

Summer is a good time to recharge our batteries.  It’s also a time to check out how the systems of care are operating when you provide (or request) vacation coverage.  If you discover care you think is inconsistent with known best practices or care that could come back to haunt facilities and providers, please contact CALTCM and our team will respond in a timely manner.  Your discovery may have wide application in our state.

Another way to recharge your batteries could be the CALTCM mentoring program and our LMG course.  I have greatly benefited from both. Go to our website: https://www.caltcm.org/ for more information on these options.

Have a great Summer!