POLST Carousel Brainstorm Activity

Instructions

The Carousel Brainstorm is an activity to get everyone involved in critical thinking

and using the material presented to solve problems. This is great to use after lunch or toward the end of the day in a full day program to energize the participants. It could also be used at a staff meeting or a shorter review session on POLST. The presenter determines the number of problems to be worked on, depending on the size of the class and the time you have for the exercise. We have provided 14

problems for you to choose from, but you may want to use 10.

General Instructions:

• Divide the class up into groups. If participants are sitting at round tables, each table could be a group.

• Each problem is printed on a different color of paper, numbered 1 to 10 (or whatever number of problems you are using).

• The instructor hands a paper to each table. The group is instructed to choose a reader and scribe for their group. This can be rotated throughout the exercise.

• Each group is instructed to read the problem and respond to the questions

asked. The scribe writes down the group’s ideas legibly.

• After a pre-determined time (2 to 5 minutes) you can ring a bell or play a chime and each table passes their paper clockwise to the next table and the process starts over again.

• At the conclusion of the process the instructor can read the problem out loud

and chooses some of the group answers that cover the intended answers.

Alternate Methods:

• If you have access to flip charts, you can have several set up around the room with the problems written on the charts and each group has a different color marker and travels around the room to the flip charts to respond to the

situations.

• Have half of the class do problems 1 to 5 and the other half do 6 to 10 and then share the situations and answers with the whole class.

• As issues come up with POLST implementation, you can write your own

scenarios and use them at staff meetings to problem-solve the issues.

We have included with each of the ten situations, Key Areas for Discussion. If the

group answers don’t touch on these areas, be sure to discuss them. This also gives

you the opportunity, as the instructor, to clarify any areas that still might not be

clear to everyone in the class (based on answers written).

Carousel Exercise 1

The patient, a 94 year old, has requested POLST Section B, Comfort Measures Only. He has had a significant stroke and now cannot make his own decisions. His son says, “I don’t care, do everything.”

What can you do or say?

Key Areas for Discussion:

a.  Review POLST with son and explain Comfort Measures.

b. Explain that it is the responsibility of all of us to honor the father’s stated

wishes. As the decision maker, it is “your job” to do “what your father

would have wanted in this situation.”

c.  Involve the physician in the conversation to discuss goals of care and the father’s wishes.

Carousel Exercise 2

An 88 year old female, living at a skilled nursing facility has a POLST; Section B is Comfort Measures Only. She is having abdominal pain and vomiting.

What should you do and why?

Key Areas for Discussion:

a. Under Comfort Measures, the POLST states, “Transfer to hospital only if

comfort needs cannot be met in current location.”

b.  Can the skilled nursing facility provide the care needed? Most can.

c.  Assessment of patient: bowels, pain, virus, etc.

d.  If patient has capacity, ask if she wants to go to the hospital.

Carousel Exercise 3

You are working at a skilled nursing facility and have a POLST signed by the

patient, but not signed by the physician. The resident requests, Do Not Attempt

Resuscitation, Limited Additional Interventions, No Artificial Means of

Nutrition. The patient complained of chest pain this morning, relieved by two

nitroglycerin pills.

What actions can you take?

Key Areas for Discussion:

a. Call physician, report patient condition, POLST choices and fax POLST

to physician immediately for signature if physician agrees that the

POLST choices are appropriate for this patient.

b. POLST is an indication of patient preference and isn’t a medical order

until signed by both the patient and physician.

c. Ask the patient and/or physician, “How often do you have chest pain like

this? Do you often take nitroglycerin with relief of chest pain?” If this is

a NEW problem or more severe than ever before, consider and discuss

further evaluation including EKG, transfer to ED, etc.

d. What does the patient want to do?

Carousel Exercise 4

You are asked to begin the POLST Conversation with a 72 year old, diagnosed

with stage 3 lung cancer three months ago, now with metastases to liver and

bones despite chemotherapy. The patient has lost 20 pounds, now weighs 115

pounds and has significant bone pain.

What aspects of the POLST Conversation are important to this person? How

can you describe comfort care?

Key Areas for Discussion:

a.  Explore what the patient knows about his/her illness and goals of care.

b.  All parts of the POLST are important to this patient.

c.  Are there significant others that should be present for this conversation?

d. Comfort Care does NOT mean No Care. Comfort Care includes active

medical treatments for pain and symptom management.

Carousel Exercise 5

Your patient is 86 years old with moderate to severe dementia, mild

hypertension, and a history of osteoarthritis with hip and knee pain. The patient

does not have decision-making capacity. You are introducing the patient’s

daughter to POLST. The daughter states, “I know that she would not want any

of this, but I feel like I have to do this.”

What can you say to the daughter? What questions can you ask her?

Key Areas for Discussion:

a. Is there an Advance Health Care Directive? If so, who is the

decision-maker and what health care wishes if any were indicated?

b. Explore the daughter’s statement and ask her, “If your Mom could talk to

us right now, what would she say about all of this?

c. Explore family issues, values, culture, or discomfort with the mother’s

choices?

Carousel Exercise 6

You are reviewing the POLST of a newly admitted patient. The POLST states:

Section A: Attempt Resuscitation

Section B: Comfort Measures Only

Section C: Long-term artificial nutrition, including feeding tubes

Is anything wrong with this? What would you do next?

Key Areas for Discussion:

a. Has the physician signed the POLST? If so, the physician would need to

be contacted.

b. Re-open the POLST conversation, since there is not congruence between

the choice in Section A and the choice in Section B. Discuss why a

request for Attempt CPR requires Full Treatment with the goal of having

the best possible outcome of CPR.

d.  Need for education of physicians and others having POLST conversations about appropriate choices.

Carousel Exercise 7

You overhear a staff member telling the daughter of a patient with advanced

dementia, “Your Mom is such a sweet lady, of course you would want us to

give her antibiotics if she got pneumonia.” Her POLST states:

Section A: Do Not Attempt Resuscitation

Section B: Comfort Measures Only

Section C: No Artificial Means of Nutrition

Do you have any concerns about this statement? If so list your concerns.

What could you say to this staff member?

Key Areas for Discussion:

a. Staff is using value-laden, guilt-inducing language.

b. Show the staff member the patient’s POLST form.

c. Educate all levels of staff on goals of care and end-of-life care.

Carousel Exercise 8

A staff person tells the family of an elderly man who has end-stage chronic obstructive pulmonary disease and is no longer eating that their dad is “starving” to death. The patient’s POLST indicates: No artificial means of nutrition, including feeding tubes.

Does this staff member seem to understand comfort and the dying process?

How might you mentor this staff person?

Key Areas for Discussion:

a.  Educate staff member, as well as the family, about process of dying.

b. Encourage staff to voice concerns with an appropriate supervisor rather

than the family.

Carousel Exercise 9

In a POLST conversation, the patient says: “I want everything done—CPR,

breathing tube, ICU, but the most important thing to me is I just want to be

comfortable when I die.”

Does this patient’s statement concern you? How might you continue the

conversation with the patient?

Key Areas for Discussion:

a.  Comfort measures are provided for everyone.

b. Explore his goals of care and give information on CPR, breathing tubes

and the lack of comfort involved with those treatments.

c. Ask the patient to describe where and how he prefers to live his last few

days; what does comfort mean to him?

Carousel Exercise 10

You are the primary care physician for Mrs. Fong, an 81 year old female, and

you introduce the POLST conversation. The oldest son interrupts you and says,

“Do not speak to my mother about this.”

What can you do?

Key Areas for Discussion:

a. Ask the son, “Tell me about your concerns with including your mother in

our conversation.”

b. Let the son know it is important what his mother knows and wants to

know, and you will be asking her, “Tell me what you understand about

what is happening to you and what you know about your illness?”

c. The patient can also be asked, “What do you want to know about your

illness?” and “Who do you want to talk with the doctor about your care?”

Carousel Exercise 11

You are preparing for a family meeting of Mr. Jong, a newly admitted 92 year

old male with Alzheimer’s Disease. He has severe contractures and is bedridden. He was admitted yesterday for aspiration pneumonia. His POLST states:

Section A: Attempt Resuscitation

Section B: Full Treatment

How will you address his POLST during the family meeting?

Key Areas for Discussion:

a. Note importance of reviewing the POLST form: what doctor signed the

POLST and when (primary care or SNF MD)?

b. What family member signed the POLST, or did the patient sign, and

when? Ask family, “What would you father say about his goals of care if

he saw his life now?”

c. Ask family what they understand about the current POLST options. Try

to assist them to understand what you expect from “Attempt CPR” with a

frail Alzheimer’s patient.

d. You can also ask the physician to discuss aspiration pneumonia and the

association with late-stage Alzheimer’s Disease.

Carousel Exercise 12

A 34 year old female is critically ill, comatose and needs consent for a surgical

procedure. Her partner visits on a daily basis. The patient has no AHCD. The

surgeon asks the nurse to call the patient’s parents to sign the consent. The RN

is aware that her partner is dedicated and visits each day.

What can the RN do?

Key Areas for Discussion:

a. Call both the family and the partner to attend a family meeting and talk

with the surgeon.

b. Discuss with the surgeon or other physicians the value of including the

partner/significant other in family meetings and with the goal of

consensus decision making.

c. As soon as the patient is capable, encourage her to complete an AHCD.

Carousel Exercise 13

A patient in a skilled nursing facility choked on a piece of toast, has turned blue and stopped breathing. The patient’s POLST states:

Section A: Do Not Attempt Resuscitation/DNR

Section B: Comfort Measures Only

What should the staff do?

Key Areas for Discussion:

a.  Perform the Heimlich maneuver (abdominal thrusts for choking).

b. Comfort measures are provided for everyone, which includes manual

treatment of airway obstruction.

c. Patient still has a pulse. She hasn’t died. Go to Section B – Medical

Interventions for guidance.

Materials used with permission from the Coalition for Compassionate Care of California, www.CoalitionCCC.org 5/23/14

9