Appendix I

(1) Physician Orders for Scope of Treatment (POST) Form. A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED Tennessee Physician Orders for Scope of Treatment (POST, sometimes called “POLST”) This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient”). Any section not completed indicates full treatment for that section. When need occurs, first follow these orders, then contact physician. Patient’s Last Name First Name/Middle Initial Date of Birth Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.  Resuscitate(CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death) When not in cardiopulmonary arrest, follow orders in B, C, and D. Section B Check One Box Only MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.  Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.  Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: basic medical treatments.  Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit. Other Instructions: Section C Check One ARTIFICIALLY ADMINISTERED NUTRITION. Oral fluids & nutrition must be offered if feasible.  No artificial nutrition by tube.  Defined trial period of artificial nutrition by tube.  Long-term artificial nutrition by tube. Other Instructions: Section D Must be Completed Discussed with:  Patient/Resident  Health care agent  Court-appointed guardian  Health care surrogate  Parent of minor  Other: (Specify) The Basis for These Orders Is: (Must be completed)  Patient’s preferences  Patient’s best interest (patient lacks capacity or preferences unknown)  Medical indications  (Other) Physician/NP/CNS/PA Name (Print) Physician/NP/CNS/PA Signature Date NP/CNS/PA (Signature at Discharge) MD/NP/CNS/PA Phone Number: TRAUMATIC BRAIN INJURY RESIDENTIAL HOMES CHAPTER 0720-38 Signature of Patient, Parent of Minor, or Guardian/Health Care Representative Preferences have been expressed to a physician and/or health care professional. It can be reviewed and updated at any time if your preferences change. If you are unable to make your own health care decisions, the orders should reflect your preferences as best understood by your surrogate. Name (print) Signature Relationship (write “self” if patient) Agent/Surrogate Relationship Phone Number Health Care Professional Preparing Form Preparer Title Phone Number Date Prepared HIPAA PERMITS DISCLOSURE OF POST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY TRAUMATIC BRAIN INJURY RESIDENTIAL HOMES CHAPTER 0720-38 Directions for Health Care Professionals Completing POST Must be completed by a health care professional based on patient preferences, patient best interest, and medical indications. To be valid, POST must be signed by a physician or, at discharge or transfer from a hospital or long term care facility, by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy. Persons with DNR in effect at time of discharge must have POST completed by health care facility prior to discharge and copy of POST provided to qualified medical emergency personnel. Photocopies/faxes of signed POST forms are legal and valid. Using POST Any incomplete section of POST implies full treatment for that section. No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.” Oral fluids and nutrition must always be offered if medically feasible. When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture). IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.” Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.” A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment. Reviewing POST This POST should be reviewed if: (1) The patient is transferred from one care setting or care level to another, or (2) There is a substantial change in the patient’s health status, or (3) The patient’s treatment preferences change. Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid. COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED. DO NOT ALTER THIS FORM (2) Advance Care Plan Form. ADVANCE CARE PLAN (Tennessee) TRAUMATIC BRAIN INJURY RESIDENTIAL HOMES CHAPTER 0720-38 I, _________________________________, hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself. Agent: I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below: Name: _____________________________ Phone #: __________ Relation:___________________ Address: ____________________________________________________________________________ Alternate Agent: If the person named above is unable or unwilling to make health care decisions for me, I appoint as alternate the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below: Name: _____________________________ Phone #: _____________ Relation: ______________ Address: _____________________________________________________________________________ My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA. When Effective (mark one):  I give my agent permission to make health care decisions for me at any time, even if I have capacity to make decisions for myself.  I do not give such permission (this form applies only when I no longer have capacity). Quality of Life: By marking “yes” below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain management. By marking “no” below, I have indicated conditions I would not be willing to live with (that to me would create an unacceptable quality of life).   Yes No Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up from the coma.   Yes No Permanent Confusion: I become unable to remember, understand, or make decisions. I do not recognize loved ones or cannot have a clear conversation with them.   Yes No Dependent in All Activities of Daily Living: I am no longer able to talk or communicate clearly or move by myself. I depend on others for feeding, bathing, dressing, and walking. Rehabilitation or any other restorative treatment will not help.   Yes No End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment. Examples: Widespread cancer that no longer responds to treatment; chronic and/or damaged heart and lungs, where oxygen is needed most of the time and activities are limited due to the feeling of suffocation. Treatment: If my quality of life becomes unacceptable to me (as indicated by one or more of the conditions marked “no” above) and my condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. By marking “yes” below, I have indicated treatment I want. By marking “no” below, I have indicated treatment I do not want.   Yes No CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.   Yes No Life Support/Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work.   Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a TRAUMATIC BRAIN INJURY RESIDENTIAL HOMES CHAPTER 0720-38 Yes No new condition but will not help the main illness.   Yes No Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which would include artificially delivered nutrition and hydration. Please sign on page 2 Page 1 of 2 Other instructions, such as burial arrangements, hospice care, etc.: (Attach additional pages if necessary) Organ donation: Upon my death, I wish to make the following anatomical gift (mark one):  Any organ/tissue  My entire body  Only the following organs/tissues:  No organ/tissue donation. SIGNATURE Your signature must either be witnessed by two competent adults or notarized. If witnessed, neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate. Signature: _______________________________________ Date: ____________________ (Patient) Witnesses: 1. I am a competent adult who is not named as the agent or alternate. I witnessed the patient’s signature on this form. Signature of witness number 1 2. I am a competent adult who is not named as the agent or alternate. I am not related to the patient by blood, marriage, or adoption and I would not be entitled to any portion of the patient’s estate upon his or her death under any existing will or codicil or by operation of law. I witnessed the patient’s signature on this form. Signature of witness number 2 This document may be notarized instead of witnessed: STATE OF TENNESSEE COUNTY OF I am a Notary Public in and for the State and County named above. The person who signed this instrument is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person who signed as the “patient.” The patient personally appeared before me and signed above or acknowledged the signature above as his or her own. I declare under penalty of perjury that the patient appears to be of sound mind and under no duress, fraud, or undue influence. TRAUMATIC BRAIN INJURY RESIDENTIAL HOMES CHAPTER 0720-38 My commission expires: __________________________ _______________________________________ Signature of Notary Public WHAT TO DO WITH THIS ADVANCE DIRECTIVE • Provide a copy to your physician(s) • Keep a copy in your personal files where it is accessible to others • Tell your closest relatives and friends what is in the document • Provide a copy to the person(s) you named as your health care agent Page 2 of 2