New CPRS Documentation Process LifeSustaining Treatment Progress Note Goals of care and lifesustaining treatment decisions Can automatically launch LST Orders LifeSustaining Treatment Orders ID: 746995
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Documenting Goals of Care Conversations AND RESOLVING CONFLICTS Slide2
New CPRS Documentation ProcessLife-Sustaining Treatment Progress NoteGoals of care and life-sustaining treatment decisionsCan automatically launch LST Orders Life-Sustaining Treatment Orders
CPR, mechanical ventilation, artificial nutrition/hydration, transfers to hospital/ICU, etc.Goals & Preferences to Inform LST PlanFor RNs, SWs, Psychologist, ChaplainsCan be used to document goals when LST decisions are not addressedSlide3
LST Progress Note
Accessible from the CPRS Cover Sheet
Does not have to be re-written on each admission unless patient’s goals or preferences change
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Default to the top of the CPRS Orders tab
Durable – do not auto-discontinue upon discharge or transfer
LST Orders
4Slide5
Create a new note
Enter title Slide6
Patient’s capacity to make decisions about LST*Surrogate
Whether documents reflecting patient’s wishes were available and reviewedPatient’s (or surrogate’s)
understanding of medical condition/prognosisGoals of care
*
Plan for use life-sustaining treatments
In the event of cardiopulmonary arrest*
In circumstances other than cardiopulmonary arrest
Consent
for plan*
LST Progress Note Template*Required fields 6Slide7
Additional options:Participants in the discussionName of supervising practitionerLinks to comfort care orders Links to
related consults (e.g., palliative care, ethics, social work, chaplain)
Mix of check boxes and free textCan be completed quickly – only four required items
LST Progress Note Template
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Help Boxes Throughout Slide9
*1. Decision-making capacitySlide10
2. Surrogate decision-makerSlide11
3. Review of documents reflecting the pt’s wishes Slide12
4. Patient’s (or surrogate’s) Understanding of Patient’s Medical ConditionSlide13
*5. Patient’s Goals of CareSlide14
6. Life-Sustaining Treatment PlanSlide15
6a. Limit LST as specified in circumstances other than cardiopulmonary arrestSlide16Slide17
*6b. Cardiopulmonary ResuscitationSlide18
7. Participants in the DiscussionSlide19
8. Consent for the LST PlanSlide20
Additional Comments, RemindersSlide21
SupervisionSlide22
Related ConsultsSlide23
Artificial nutritionArtificial hydrationMechanical ventilation
LST OrdersSlide24
LST OrdersTransfersOther LST
NO LST in circumstances OTHER than cardiopulmonary arrestSlide25
LST Orders
Facilities can use “DNR” or “DNAR”
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In the event of cardiopulmonary arrest:
DNR: Do not attempt CPR.
DNR with exception: ONLY attempt CPR during the following procedure: (specify)
For use when the patient would not want CPR
unless
they experienced a cardiopulmonary arrest during a specific planned procedure (e.g., surgery, dialysis)Slide26
LST Orders
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In circumstances other than cardiopulmonary arrest:
Full scope of treatment
No life-sustaining treatment
Limit life-sustaining treatment as specified:
For indicating limits to artificial nutrition, artificial hydration, mechanical ventilation, other LSTs, transfers to the hospital or ICUSlide27
Goals of Care Conversation WorksheetHelpful for taking notes during the conversationFollows the flow of the LST Progress NoteSlide28
Documenting Changes Write an addendum to existing LST note Write
new LST orders from the LST menu on the Orders tabD/C obsolete LST orders on the Orders tab
OR….Write a new LST note (launches new LST orders)
D/C
obsolete LST orders
on the Orders tabSlide29
Additional Progress Note for Documenting Goals when LST Decisions Have Not Been Made
For other team members who do not make shared decisions with patients about LSTsCan be used by MDs/APRNs/PAs when LST decisions have not
yet been madeRECOMMENDED TITLE:
Goals & Preferences to Inform Life-Sustaining Treatment Plan
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Important Process Change
LST Orders specify LIMITS to life-sustaining treatmentNo “full code” ordersFor high-risk patients
, document full code discussions and decisions in the LST noteFor non-high-risk patients
, document full code discussions and decisions in
progress note for that encounterSlide31
Important Process Change
LST orders are durableOutpatients may have active LST ordersPatients may be admitted with active LST ordersCheck Postings and Orders tabReview with the patient (or surrogate)
If changes, document in LST notes and ordersSlide32
Important Process Changes
APRNs and PAs may write LST notes and ordersNo need for attendings to re-enter LST orders if they have already been written by a residentSupervision is documented through an addendum or co-signature to the LST note Slide33
Establishing an LST plan when the patient lacks capacity and has no surrogateDocument recommended goals of care and LST plan
based on patient’s known values/preferences or, if those are unknown, best interestsContact the LST Multidisciplinary Committee for review. Proposed plan is reviewed by the Multidisciplinary Committee, Chief of Staff, and Medical Center Director.
After proposed plan has been approved, write LST Note and Orders.
LST Note and Orders can be written
prior
to Multidisciplinary Committee review if patient has a state-authorized portable order (e.g., POLST)Slide34
Inconsistencies Between LST Orders, SAPOs, Advance DirectivesDocument with the most recent date general supersedesSlide35
Q: What if a surrogate wants to override a patient’s documented wishes and change the existing LST plan?Slide36
1. Maintain supportive relationship while addressing goals and LST decisions.Express empathy throughout
It must be hard to see your dad this sick.Review the surrogate’s role: to convey to the team what the patient would decide in these circumstancesAssess the surrogate’s understanding of the patient’s condition, prognosis
Thank the surrogate for playing this important and stressful role!Slide37
2. Explore together the evidence of the patient’s goals/preferencesLST notes, ordersAdvance directivesState-authorized portable orders
Discussions between the patient and others Other indications of the patient’s valuesSlide38
3. Explore surrogate’s concernsMay be concerned about “killing” the patient by agreeing to LST limitsMay be concerned about family conflict
May be feeling intense grief, guilt, anger, or fearSlide39
4. If the surrogate cannot present compelling evidence that the patient would want to change their LST plans in the present circumstances…
…request an ethics consult.Slide40
5. If the conflict is not resolved through the Ethics Consultation process:Facility Director must make a decision on behalf of the facility and follow the VISN clinical appeals process
(VHA Directive 2006-057)Decisions to limit LST over the objection of the surrogate must be based on at least one of the following criteria: The treatment is…Clearly inconsistent with the patient’s known values & preferences
Clearly ineffective and has no chance of accomplishing the patient’s goals of careClearly inconsistent with prevailing medical standards or VA national policy or guidelines;Clearly ineffective and has no chance of producing its intended physiologic effect (e.g., unsubstantiated alleged cancer treatments)Slide41
6. Before writing new LST orders over the objection of the surrogate:The Director must:Notify the surrogate of the decision & the plan to write LST orders
Inform the surrogate about the clinical appeals process & option to request a transferNew LST orders should only be written after the process related to a clinical appeal or transfer have been concluded.Slide42
7. To help prevent these situationsInclude surrogates and families in proactive goals of care conversations with patients
Explore whether the surrogate would have difficulty supporting the patient’s goals or LST decisionsExplain the benefits of proactive decisions make by the patient – takes the decision-making burden off the surrogateSlide43
7. To help prevent these situations CONTINUED
How you present the patient’s decisions to the surrogate makes a difference!When your mother met with Dr. Jones about two months ago, she knew her illness was getting worse, and she said it was her goal to stay as comfortable as possible.
She wanted medical orders written so she wouldn’t be put on a breathing machine or get CPR. Those orders are in place so everyone will know to honor her wishes. Is there anything more you can share to help us respect her decisions?Slide44