CPR Directives and MOST Forms
HOSPICE AND PALLIATIVE CARE
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09:03 AM -- CPR Directives and MOST Forms
Mr. Randy Kuykendall, Section Chief, Emergency Medical and Trauma Services Section within the Colorado Department of Public Health and Environment, began his presentation related to CPR directives and Medical Orders for Scope of Treatment (MOST). He noted that the Emergency Medical and Trauma Services Section is responsible for overseeing CPR directives and described the history and the use of CPR directives in the state. He stated that emergency personnel are not experts in recognizing the differences between forms, and the goal of Colorado's CPR directive statute was to create an easily recognizable form. Up until now, the form has been in a standardized format which is produced in triplicate and must be signed by a physician. He stated that access to the form can be difficult, and that the CPR directive is only one of many different forms relating to end-of-life decisions. He stated that two years ago, the division undertook a revision of the form, and has been working with various stakeholders on the revisions. After a public comment period, the next step is to submit the revisions to the State Board of Health. He stated that the biggest difference between the old and new forms is that the CPR directive will no longer be in a prescribed format. By statute, the form will still require a physician's signature. In addition, Mr. Kuykendall noted that the revisions will allow for copies of the CPR directive to be valid. He described how emergency calls are handled by paramedics, noting that sometimes CPR and advance directive forms cannot be found, and that, in the absence of those forms, medical providers will attempt to resuscitate a patient.
Mr. Kuykendall responded to questions from Representative Riesberg regarding whether copies of the forms will be accepted, and whether copies of the forms are currently accepted. He responded that copies will be accepted and the goal is to make the form and the process more accessible. He responded to additional questions regarding training for individuals on where to keep advance directive forms, noting that people are trained to keep such forms in their freezer and medical personnel check freezers for the forms. He further responded to questions regarding bracelets that alert emergency personnel to the existence of advance directive forms. Mr. Kuykendall responded to additional questions from Representative Roberts regarding the need for education regarding advance directive forms, stating that education begins with the patient. Additionally, education for caregivers and the community is important. He stated that anything that could simplify the decisions related to resuscitating patients in an emergency situation will help. He stated that if the form is overly long, in an emergency situation, emergency personnel may default to resuscitation if they cannot quickly understand what the form is saying. Representative Roberts asked whether it is a problem that Colorado has at least four advance directive forms, and Mr. Kuykendall responded that from a prehospital care perspective, it doesn't help to have so many forms. However, once the patient has entered the acute care system, the forms may be helpful. In response to a question from Representative Roberts, he stated that the living will is not entirely useful in a prehospital setting.
Mr. Kuykendall responded to questions from Senator Williams regarding incidents in which terminally-ill patients were resuscitated only to pass away in the intensive care unit days later. He stated that family members often do not know what to do, and call in emergency personnel to treat even terminally ill individuals. He responded to additional questions regarding stakeholder input into the process of revising the CPR form. Senator Tochtrop discussed the education of patients in long-term care facilities and their families regarding end-of-life decisions.
Mr. Kuykendall spoke to the MOST form. He explained that the MOST form goes beyond CPR directives and gives more information. He stated that it hasn't been fully tested in Colorado, and that there are pilots that are testing the form. He stated that if the form assists providers in making decisions, it will be useful, but the form also allows for more information, which could cause confusion. A copy of the MOST form was distributed to the committee (Attachment B). The committee discussed the requirement that a physician sign a CPR directive.
Representative Roberts asked if there is more that can be done to provide liability protection to health care workers who follow advance directive forms. She also discussed whether lawyers or additional individuals should have the ability to assist individuals in creating a CPR directive. Mr. Kuykendall responded that it would be helpful to bring the CPR directive in line with the other forms and allow additional individuals to certify the form. He stated that there are a lot of issues involved with CPR forms, including making sure the patient understands the circumstances under which he or she will or won't be resuscitated. Mr. Kuykendall responded to Representative Robert's questions regarding liability, stating that liability protection is key and is in place, and that a better job needs to be done explaining what the protection means and encouraging providers to use the protection. Senator Tochtrop commented on who can sign the MOST form. Senator Williams commented on the need for revision of the "yellow form" that is given to patients in hospitals regarding health care decision making, and whether it could be better coordinated with the MOST form. Mr. Kuykendall noted that there are pilot projects underway to evaluate the MOST form, and reminded the committee that the emergency community advocates for simple forms.
Mr. Kuykendall thanked the committee and noted that the department's focus is on CPR directives. He noted that MOST forms and Physicians Orders for Life-Sustaining Treatment (POLST) forms have broader implications outside of the emergent environment.