What is a POST?
POST stands for Physician Orders for Scope of Treatment. It is a physician’s order (also referred to as a medical order) that communicates the plan of care which respects the patient’s wishes concerning care at the end of life.
Who should have a POST?
A POST is primarily intended for the patient who expects death within the next twelve (12) months. In addition, a POST is appropriate for those who have an advanced chronic, progressive illness or progressive dementia, which may result in loss of decision-making ability.
When should a POST be completed?
The POST should be completed after discussion with a trained facilitator or qualified healthcare professional as well as discussion with and review by the physician. The patient and physician must agree that a POST is an appropriate tool for making sure the patient’s wishes are known. A POST is not considered complete without the patient’s or patient representative’s signature.
What is the goal of the POST initiative?
The goal of the POST initiative is to inform and empower patients to clearly state their end-of-life care wishes, and to authorize healthcare providers to carry out those wishes. As a portable medical order, healthcare providers at every level and setting can implement the decisions outlined in the POST.
Will all healthcare providers recognize the POST form?
The POST form is printed on white paper and placed in a bright pink manila envelope for easy identification by healthcare providers.
Will all healthcare providers follow the wishes expressed in the POST?
The wishes expressed in the POST may be followed by any healthcare provider or facility. However, some providers, particularly facilities such as hospitals, typically recognize only those medical orders written by their credentialed medical staff. In this case, the hospital’s medical staff should quickly review the decisions documented on the POST with the patient (or representative) and use the POST form for guidance in issuing in-hospital orders concerning the patient’s care. Facilities’ policies regarding recognition of the POST form may vary for emergency and non-emergency situations.
Why not just use the current DNR form?
The current DNR form is effective in support of patients’ CPR decisions, and may continue to be an important tool for some patients. The POST allows the seriously ill patient to outline more comprehensive choices about end-of-life care following a discussion with his/her healthcare provider. Those choices may include CPR, level of care when in distress (full, limited or comfort care) and artificial nutrition. These choices provide more in-depth guidance for the patient’s end-of-life care, whereas the DNR form only addresses CPR.
Are other states using forms like POST?
Yes. All but three states and the District of Columbia are utilizing the POST (or their equivalent) document at either the mature, endorsed or developing level. There is also a national effort known as the POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to support those who are in the development stage of their program. Further information regarding the POLST paradigm may be found at http://www.polst.org/ . The original form was developed in Oregon in 1991.
Has the POST form been legislated into a law?
No. At present, the POST project remains in the pilot stage. It originally rolled out in Greenville and Charleston counties. It is now in the process of expanding into several other counties. If the pilot project reveals positive results, it is the hope that it will become legislated in our state.
What is the difference between a POST and an advance directive?
Advance directives such as the Living Will and Healthcare Power of Attorney are legal instruments completed by individuals that require witnesses and/or notarization. The Living Will informs physicians and other healthcare providers regarding the level and type of care desired by the patient in a specific end-of-life situation if the patient is no longer capable of making or communicating these decisions, and must be witnessed and notarized. A Healthcare Power of Attorney designates a person who can make healthcare decisions on behalf of the patient if the patient is unable to do so, and must be witnessed while notarization is optional. However, to carry out a patient’s wishes regarding the level of care provided, a physician or medical order is needed.
The POST is a medical order issued by a physician that also requires informed consent/agreement of the patient or the legally appointed representative. Unlike an advance directive, a POST is always completed in consultation with a qualified healthcare professional that is able to provide information to the patient or the patient’s representative about the risks, benefits, and other implications of different types and levels of medical treatment.
As in all physician orders, the POST instructs other healthcare providers regarding the type and level of care to be provided. The POST does not require witnesses or notarization. The POST is the first medical order in South Carolina to require a patient or patient representative signature on the form.
The POST is not meant to replace an advance directive, but to complement it. It is another mechanism to ensure that patient wishes for medical treatment at the end of life are known and honored.
Why does the patient or the patient representative need to sign the POST?
The patient or patient representative signature requirement provides evidence of informed consent and enhances the acceptability of the form. According to Section 44-66-50 (B) of the SC Adult Health Care Consent Act “This chapter does not authorize the provision of health care to a patient who is unable to consent if the attending physician or other health care professional responsible for the care of the patient has actual knowledge that the health care is contrary to the patient’s unambiguous an uncontradicted instructions expressed at a time when the patient was able to consent.”. The patient’s or patient representative’s signature helps give the healthcare provider “actual knowledge” of the patient’s wishes.
Also, the national POLST Paradigm Task Force strongly recommends that the patient or patient representative signature be required.
Are there any exceptions to the patient's or patient representative's signature requirement?
Yes, but only one. If the patient is no longer able to make and communicate decisions, and the patient representative is not physically available at the patient location, the healthcare professional may prepare the form in consultation with the patient representative via telephone, electronic means, or other means. The prepared form may be sent via fax or other electronic means to the patient representative, who may then sign the form and return it to the healthcare professional. The signed copy must then be put into the patient’s record.
Under what circumstances may a patient representative authorize and sign a POST?
A patient representative may authorize and sign a POST only when the patient is no longer able to make or communicate decisions. If a Healthcare Power of Attorney is not in place, who serves as the patient representative is determined by the hierarchy set for Section 44-66-30 of the SC Adult Health Care Consent Act.
Are copies of the POST form acceptable?
Yes, copies are legal and valid. It is recommended that not too many copies be distributed in case a form is revoked or changed. It may be difficult to “recall” all copies, resulting in contradictory forms. In the case of two different forms being presented, the healthcare provider should use the form with the most recent date. The original form should remain with and accompany the patient as he/she moves from one healthcare setting or level of care to another.
Are multiple originals of the POST form acceptable?
No, only one original is generated since copies are considered legal and valid.
What sections must be completed for a POST to be valid?
All fields of the form are to be completed. If any treatment sections are not completed, it is implied that the full treatment will be rendered.
Is a POST mandatory?
No, as with advance directives, having a POST is voluntary.
How does a patient or patient representative obtain a POST?
As a medical order, the form is available to patients and/or representatives only through the pilot project healthcare facilities for the duration of the pilot project.
Who fills out the POST form?
The POST form may be initiated by a trained facilitator or qualified healthcare professional in consultation with the patient or patient representative. This helps to ensure that the patient and/or patient representative will understand the levels and types of medical treatment. It is strongly encouraged for any patient representative to be present during the discussions regarding the POST. Ultimately, the physician must review and discuss the POST with the patient and/or patient representative. Once that is completed, the POST is signed by the patient and the physician.
Which healthcare providers can issue/sign a POST?
For the purposes of the pilot project, physicians practicing at the pilot healthcare facilities may issue/sign a POST. The form may be initiated, at the request of the patient, by a trained facilitator or qualified healthcare professional.
Is a POST valid without the signature of a physician?
No. It is a medical order and must have the signature of the physician.
How do the physicians obtain the POST form?
Each pilot healthcare facility is provided with numbered forms. If more forms are needed, they can be obtained by contacting Wilma Rice, MSN, RN, CEN at firstname.lastname@example.org .
Should patients or their representatives be presented with a POST form to complete when they come into an emergency department?
No. The POST form is not designed to be completed in an emergency situation. An in-depth discussion between the patient and/or representative and a trained facilitator or qualified healthcare professional should be held prior to signing a POST. In addition, the signing physician must discuss and review the form prior to signing. The purpose of a POST is to document one’s healthcare choices in advance to avoid crisis decision-making in an emergency situation.
How long is a POST form valid?
The POST is valid until revoked or changed by the patient or patient representative. It is recommended that the form be reviewed at least annually, whenever the patient is admitted/discharged from a healthcare facility, a substantial change in patient’s condition, and if a change in the patient’s preferences occurs. The form may be revoked by oral or written statement by the patient or patient representative or by mutilating, obliterating or destroying the document. It is recommended that a line be drawn diagonally across the face of the form and the date/initials of the person voiding the document be written on the line to indicate revocation of the form.
What protections are there for healthcare providers who follow the orders on a POST form?
The POST form is not legislated in South Carolina. However, as previously stated in Question 11, Section 44-66-50 (B) does state that if a healthcare professional has “actual knowledge” of a patient’s wishes, he/she is not required to provide care against those “. . .unambiguous and uncontradicted instructions expressed at a time when the patient was able to consent.” However, due to facility policies, the receiving physician may be required to review the POST and write the patient’s wishes on facility-generated order forms.
Where should a POST be stored?
As a portable medical order, where it is placed will depend on the location of the patient. If the patient is in a healthcare facility, the posting of the original POST form will be determined by facility policy or direction. If the patient is at home, the original POST form should be in an easily visible location such as over the patient’s bed, on the door to the patient’s bedroom or on the refrigerator.
What if one of Sections A-C is not completed?
Any section (A-C) that addresses medical treatment or intervention that is not completed will result in full treatment for that category of care. A healthcare provider who notes that a section of the POST form is incomplete should consider discussing the implications with the patient and/or patient representative. If clear decisions are made about the incomplete sections, it would be appropriate to revise the POST form.