SLS 16RS-584 ORIGINAL
2016 Regular Session
SENATE BILL NO. 360
BY SENATOR MILLS
HEALTH CARE. Provides for the Louisiana Physician Orders for Scope of Treatment
(LaPOST) form. (gov sig)
1 AN ACT
2 To amend and reenact R.S. 40:1155.2(8), relative to the Louisiana Physician Order for
3 Scope of Treatment; to provide for definitions; to provide for form modifications;
4 to provide for specific language to be utilized on the form; to provide for mandatory
5 fields; to provide for an effective date; and to provide for related matters.
6 Be it enacted by the Legislature of Louisiana:
7 Section 1. R.S. 40:1155.2(8) is hereby amended and reenacted to read as follows:
8 ยง1155.2. Definitions
9 As used in this Subpart, the following terms shall have the meanings ascribed
10 to them unless the context clearly states otherwise:
11 * * *
12 (8) "Louisiana Physician Order for Scope of Treatment" means a form which
13 documents the wishes of a qualified patient in a physician order. The following
14 statements shall appear at the bottom of each page of the form: "Send form with
15 person whenever transferred or discharged. Use of original form is strongly
16 encouraged. Photocopies and faxes of signed LaPOST forms are legal and valid".
17 The form shall include certain fields which provide information, instructions, and
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1 areas to record information. The fields shall include but not be limited to the
2 following:
3 (a) A field stating "HIPAA permits disclosure of LaPOST to other health care
4 providers as necessary".
5 (b) A field identifying the form as "Louisiana Physician Orders for Scope of
6 Treatment".
7 (c) A field providing an instruction which reads: "First follow these orders,
8 then contact physician. This is a physician order sheet based on the person's medical
9 condition and wishes. Any section not completed implies full treatment for that
10 section. Everyone shall be treated with dignity and respect. Please see
11 www.La-POST.org for information regarding "what my cultural/religious heritage
12 tells me about end of life care"".
13 (d) Fields for recording the last name, first name, middle initial, and date of
14 birth and medical record number of a qualified patient. The medical record
15 number shall be optional and indicated as optional in parenthesis on the form.
16 (e) A field titled "Patient's diagnosis of life-limiting disease and irreversible
17 condition" with an area below to record information. In the same field there shall
18 also be an area titled "Goals of Care" with an area below to record information.
19 (f) A field titled "A. Cardiopulmonary resuscitation (CPR): person has no
20 pulse and is not breathing". This field shall provide an instruction which reads
21 "check one" and shall further provide two options for selection. The two options
22 shall be labeled as follows:
23 (i) "CPR / attempt resuscitation (requires full treatment in Section B)".
24 (ii) "DNR / do not attempt resuscitation (allow natural death)".
25 (g) A field titled "B. Medical interventions: person has pulse or is breathing".
26 This field shall provide an instruction which reads "check one" and shall further
27 provide three options for selection and one area to record additional orders. The four
28 items shall be labeled as follows:
29 (i) "Comfort measures only: Use medication by any route, positioning,
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SLS 16RS-584 ORIGINAL
1 wound care and other measures to relieve pain and suffering. Use oxygen, oral
2 suction and manual treatment of airway obstruction as needed for comfort. Patient
3 prefers no transfer: EMS contact medical control to determine if transport indicated".
4 "Full treatment (primary goal of prolonging life by all medically effective
5 means). Use treatments in Selective Treatment and Comfort Focused treatment.
6 Use mechanical ventilation, advanced airway interventions and cardioversion
7 if indicated".
8 (ii) "Limited additional interventions: Includes care described above. Use
9 medical treatment, IV fluids and cardiac monitor as indicated. Do not use
10 intubations, advanced airway interventions, or mechanical ventilation. Transfer to
11 hospital if indicated. Avoid intensive care unit if possible". "Selective treatment
12 (primary goal of treating medical conditions while avoiding burdensome
13 treatments). Use treatments in Comfort Focused treatment. Use medical
14 treatment, including IV antibiotics and fluids as indicated. May use noninvasive
15 positive airway pressure (CPAP/BiPAP). Do not intubate. Generally avoid
16 intensive care".
17 (iii) "Full treatment: Includes care described above. Use intubation, advanced
18 airway interventions, mechanical ventilation. Transfer to hospital if indicated,
19 includes intensive care unit". "Comfort focused treatment (primary goal is
20 maximizing comfort). Use medication by any route to provide pain and
21 symptom management. Use oxygen, suctioning and manual treatment of airway
22 obstruction as needed to relieve symptoms. (Do not use treatments listed in full
23 or selective treatment unless consistent with goals of care. Transfer to hospital
24 ONLY if comfort focused treatment cannot be provided in current setting.)"
25 (iv) "Additional orders (e.g. dialysis, etc.)"
26 (h) A field titled "C. Antibiotics". This field shall provide an instruction
27 which reads "check one" and shall further provide three options for selection and one
28 area to record additional orders. The four items shall be labeled as follows:
29 (i) "No antibiotics. Use other measures to relieve symptoms".
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1 (ii) "Use antibiotics if life can be prolonged".
2 (iii) "Determine use or limitation of antibiotics when infection occurs, with
3 comfort as goal. (Benefit of treatment should outweigh burden of
4 treatment)".
5 (iv) "Additional orders:"
6 (i)(h) A field titled "D C. Artificially administered fluids and nutrition:
7 (Always offer food / fluids by mouth as tolerated)". This field shall contain the
8 statement "The administration of nutrition and hydration, whether orally or by
9 invasive means, shall always occur except in the event another condition arises,
10 which is life-limiting or irreversible in which the nutrition or hydration becomes a
11 greater burden than benefit to patient". "Medically assisted nutrition and
12 hydration is optional when it cannot reasonably be expected to prolong life,
13 would be excessively burdensome or would cause significant physical
14 discomfort". This field shall provide an instruction which reads "check one in each
15 column" and shall further provide a column listing three options for selection, a
16 column listing two options for selection, and one area to record additional orders.
17 The six three items shall be labeled as follows and contain the following text,
18 respectively:
19 (i) A column shall list:
20 (aa) "No artificial nutrition by tube".
21 (bb) "Trial period of artificial nutrition by tube (Goal:__________)".
22 (cc) "Long-term artificial nutrition by tube (if needed)".
23 (ii) A column shall list:
24 (aa) "IV fluids (Goal:__________)".
25 (bb) "No IV fluids".
26 (iii) "Additional orders:"
27 (j) A field titled "E. Other instructions: (May include additional guidelines
28 for starting or stopping treatments in sections above or other directions not addressed
29 elsewhere)".
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1 (k)(i) A field titled "F D. Summary of goals" which shall comprise the
2 following two parts:
3 (i) An area providing an instruction which reads "check one" and further
4 providing the text "Discussed with" and the following two options for selection:
5 (aa) "Patient".
6 (bb) "Personal health care representative".
7 (ii) An area providing an instruction which reads "check all that apply" and
8 further providing the text "The basis for these orders is:" and the following four
9 items for selection:
10 (aa) "Patient's declaration (can be oral or nonverbal)".
11 (bb) "Patient's personal health care representative (qualified patient without
12 capacity)."
13 (cc) "Patient's advance directive, if indicated, patient has completed an
14 additional document that provides guidance for treatment measures if he/she loses
15 medical decision-making capacity".
16 (dd) "Resuscitation would be medically non-beneficial".
17 (ee) "Advance directive dated" with a space to insert the date and
18 "available and reviewed".
19 (ff) "Advance directive not available".
20 (gg) "No advance directive".
21 (hh) "Health care agent if named in advance directive:" with an area to
22 provide a name and phone number.
23 (ii) A field with the statement "This form is voluntary and the signatures
24 below indicate that the physician orders are consistent with the patient's
25 medical condition and treatment plan and are the known desires or in the best
26 interest of the patient who is the subject of the document".
27 (l)(j) Fields A section to include fields for recording the name, signature,
28 and phone number of a physician. A field for the date indicating that a date is
29 mandatory.
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1 (m)(k) Fields, labeled "Mandatory," for recording the name and signature
2 of the patient or personal health care representative and the date of such signature
3 including an indication that the date is mandatory.
4 (n)(l) A field stating "If personal health care representative, state relationship
5 and authority to act on behalf of patient". "PHCR relationship" with a place to
6 notate the relationship, a field stating "PHCR address" with a place to note the
7 address, and a field stating "PHCR phone number" with a place to note the
8 phone number.
9 (o)(m) A field titled "Directions for health care professionals" which shall
10 consist of three sections, labeled as follows, and state the following information,
11 respectively:
12 (i) A section labeled "Completing LaPOST" which shall state the following:
13 (aa) "Must be completed by a physician and patient or their personal
14 health care representative based on patient the patient's medical conditions and
15 preferences and medical indications for treatment".
16 (bb) "LaPOST must be signed by a physician to be valid. Verbal physician
17 orders are acceptable with follow-up signature by physician in accordance with
18 Louisiana law".
19 (cc) "Use of the brightly colored original form is strongly encouraged.
20 Photocopies and faxes of signed LaPOST are legal and valid".
21 (ii) A section labeled "Using LaPOST" which shall state the following:
22 (aa) "Completing a LaPOST form is voluntary. Louisiana law requires
23 that a LaPOST form be followed by health care providers and provides
24 immunity to those who comply in good faith. In the hospital setting, a patient
25 will be assessed by a physician who will issue appropriate orders that are
26 consistent with the patient's preferences".
27 (bb) "LaPOST does not replace the advance directive. When available,
28 review the advance directive and LaPOST form to ensure consistency and
29 update forms appropriately to resolve any conflicts".
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SLS 16RS-584 ORIGINAL
1 (cc) "The personal health care representative is defined under R.S.
2 40:1299.53 and may execute the LaPOST form only if the patient lacks capacity
3 or has designated that the PHCR authority is effective immediately".
4 (dd) "LaPOST must be signed by a physician and the patient or PHCR
5 to be valid. Verbal orders are acceptable with follow up signatures by the
6 physician according to facility and community policy".
7 (ee) "If the form is translated, it must be attached to a signed LaPOST
8 form in ENGLISH".
9 (aa)(ff) "Any section of LaPOST not completed implies full treatment for that
10 section".
11 (bb)(gg) "A semi-automatic external defibrillator (AED) should not be used
12 on a person who has chosen "do not attempt resuscitation"".
13 (hh) "Medically assisted nutrition and hydration is optional when it
14 cannot reasonably be expected to prolong life, would be excessively burdensome
15 or would cause significant physical discomfort".
16 (cc) "Even if a patient chooses "no artificial nutrition by tube" or "no IV
17 fluids" or "trial period of artificial nutrition by tube," the administration of nutrition
18 and hydration, whether orally or by invasive means, shall always occur except in the
19 event another condition arises which is life-limiting and irreversible in which
20 nutrition and hydration by any means becomes a greater burden than benefit to
21 patient".
22 (dd)(ii)"When comfort cannot be achieved in the current setting, the person,
23 including someone with "comfort measures only focused treatment," should be
24 transferred to a setting able to provide comfort (e.g. pinning of a hip fracture)".
25 (ee)(jj) "A person who chooses either "comfort measures only selective
26 treatment" or "limited additional interventions comfort focused treatment" should
27 not be entered into a Level I trauma system".
28 (ff)(kk) "A parenteral (IV/Subcutaneous) medication to enhance comfort may
29 be appropriate for a person who has chosen "comfort measures only focused
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SLS 16RS-584 ORIGINAL
1 treatment"".
2 (gg)(ll) "Treatment of dehydration is a measure which may prolong life. A
3 person who desires IV fluids should indicate "limited interventions selective
4 treatment" or "full treatment"".
5 (hh)(mm) "A person with capacity or the personal representative (if the
6 patient lacks capacity) can revoke the LaPOST at any time and request alternative
7 treatment based on the known desires of the individual; or, if unknown, the
8 individual's best interests".
9 (ii)(nn) "Please see links on www.La-POST.org for "what my
10 cultural/religious heritage tells me about end of life care"".
11 (jj)(oo) "The duty of medicine is to care for patients even when they cannot
12 be cured. Physicians and their patients must evaluate the use of technology available
13 for their personal medical situation. Moral judgments about the use of technology to
14 maintain life must reflect the inherent dignity of human life and the purpose of
15 medical care".
16 (iii) A section labeled "Reviewing LaPOST" which shall provide the
17 following:
18 (aa) The statement: "This LaPOST should be reviewed periodically such as
19 when the person is transferred from one care setting or care level to another, or there
20 is a substantial change in the person's health status. A new LaPOST should be
21 completed if the patient wishes to make a substantive change to their treatment goal
22 (e.g. reversal of prior directive). When completing a new form, the old form must be
23 properly voided and retained in the medical chart. To void the LaPOST form, draw
24 a line through "Physician Orders" and write "void" in large letters. This should be
25 signed and dated".
26 (bb) A chart titled "Review of this LaPOST form" consisting of four columns
27 which are titled as follows:
28 (I) "Review date and time".
29 (II) "Reviewer".
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SLS 16RS-584 ORIGINAL
1 (III) "Location of review".
2 (IV) "Review outcome". Each row in this column shall contain the following
3 two options for selection:
4 (aaa) "No change".
5 (bbb) "Form voided and new form completed".
6 * * *
7 Section 2. This Act shall become effective upon signature by the governor or, if not
8 signed by the governor, upon expiration of the time for bills to become law without signature
9 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
10 vetoed by the governor and subsequently approved by the legislature, this Act shall become
11 effective on the day following such approval.
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Christine Arbo Peck.
DIGEST
SB 360 Original 2016 Regular Session Mills
Present law provides for patient identifying information. Proposed law adds patient medical
record number as an optional identifier.
Present law provides a field for patient's diagnosis of life limiting disease and irreversible
condition. Proposed law adds information in the same field to identify goals of care.
Present law provides for medical interventions. Proposed law updates medical interventions
to clarify that treatments are not limited, but intentionally selected.
Present law provides for a basis on which the orders are made. Proposed law adds additional
basis options specific to the advance directive or lack thereof.
Present law provides for instructions on completing a LaPOST form. Proposed law adds
additional language to clarify that a LaPOST form is voluntary and does not replace the
advance directive.
Effective upon signature of the governor or upon lapse of time for gubernatorial action.
(Amends R.S. 40:1155.2(8))
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