Using POST the Right Way: Misperceptions Place Facilities at Risk of Misuse By Susan Hickman, PhD – Indiana University School of Nursing

Using POST the Right Way: Misperceptions Place Facilities at Risk of Misuse
By Susan Hickman, PhD – Indiana University School of Nursing

 

The Indiana POST (Physician Orders for Scope of Treatment) program is designed to document resident treatment preferences as medical orders that guide care in the nursing facility and accompany residents to the hospital. The goal is to ensure that resident preferences are known and honored by all who provide care. POST is central to providing person-centered care. However, there are misperceptions about its use that can lead to problems.

POST-appropriate residents.

POST is designed for residents with advanced chronic progressive illness, frailty, terminal conditions, or residents who are unlikely to survive cardiopulmonary resuscitation.

Who can sign POST

Residents must be of sound mind when the form is completed. If the resident is able to make his or her own decisions, it should be discussed with the resident – not the family! If the resident lacks decisional capacity, it can be completed by their legally appointed representative (health care representative or power of attorney for health care). It must also be signed by a physician or advanced practice providers (APRN, PA).

POST should not be used as a code status order

At least some nursing facility residents are ineligible for POST because they do not meet diagnostic criteria or lack capacity and do not have a legally appointment representative. This realty makes policies requiring POST for all residents highly problematic. Moreover, using POST just as a code status order represents a missed opportunity to discuss goals, values, and preferences.

Best practices for completing POST

POST requires a conversation that includes education and a discussion of the resident’s current medical condition, along with preferences, goals, and values. POST should never be handed to family members at admission with a request they return it filled out.

POST is always voluntary

A facility may have a policy offer POST to qualified residents, but a resident cannot be required to complete a POST. Facilities with policies requiring POST completion for all residents are in violation of Indiana code. Additionally, a resident (or their legal representative) can request alternative treatment or revoke the existing POST at any time.

Re-evaluating POST

POST should be re-evaluated routinely and when there is a significant change in condition to ensure the orders reflect the resident’s current preferences. This practice is consistent with the CMS Requirements of Participation.

Comfort Measure orders are different than hospice

Comfort measures orders reflect a preference to avoid hospitalization and focus on symptom management. A resident with a preference for comfort measures does not need to be on hospice in order to receive comfort-focused care in the nursing facility.

Providers are required to honor POST orders

Indiana code requires POST orders to be honored throughout the healthcare system. Facilities should have policies and procedures for use of POST and for communicating the preferences recorded on POST to the treating provider. If a resident is admitted to your facility with a POST, the facility is required to honor those orders.

Train your staff

Create policies and procedures to ensure code status and POST orders are consistently documented and known by staff. To communicate orders in an emergency, strategies include a colored dot on the chart, a sticker on the inside front of the chart, including code status and POST orders on the resident’s face page, or creating a facility order sheet at the front of the chart to be completed when a POST or code status order is written. Additional POST education resources including videos for staff as well as residents/family members are available at www.indianapost.org .

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New Resource!

Check out the recently updated indianapost.org website for updates including brief educational videos and translated versions of the Indiana POST! The website is maintained by a group of stakeholders called the Indiana Patient Preferences Coalition.