SLS 16RS-584 ENGROSSED
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 (LaPOST)".
7 (c) A field providing an instruction which reads: "First follow these orders,
8 then contact physician. This is a physician order sheet form based on the person's
9 medical condition and wishes preferences. Any section not completed implies full
10 treatment for that section. LaPOST complements an Advance Directive and is not
11 intended to replace that document. Everyone shall be treated with dignity and
12 respect. Please see www.La-POST.org for information regarding "what my
13 cultural/religious heritage tells me about end of life care"".
14 (d) Fields for recording the last name, first name, middle initial name, and
15 date of birth and medical record number of a qualified patient. The medical
16 record number shall be optional and indicated as optional in parenthesis on the
17 form.
18 (e) A field titled "Patient's diagnosis of life-limiting disease and irreversible
19 condition" with an area below to record information. In the same field there shall
20 also be an area titled "Goals of Care" with an area below to record information.
21 (f) A field titled "A. Cardiopulmonary resuscitation (CPR): person has no
22 pulse is unresponsive, pulseless and is not breathing". This field shall provide an
23 instruction which reads "check one" and shall further provide two options for
24 selection. The two options shall be labeled as follows:
25 (i) "CPR / attempt resuscitation (requires full treatment in Section B)".
26 (ii) "DNR / do not attempt resuscitation (allow natural death)".
27 (g) A box containing the following statement: When not in
28 cardiopulmonary arrest, follow orders in B and C.
29 (h) A field titled "B. Medical interventions: person has pulse or is breathing".
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1 This field shall provide an instruction which reads "check one" and shall further
2 provide three options for selection and one area to record additional orders. The four
3 items shall be labeled as follows:
4 (i) "Comfort measures only: Use medication by any route, positioning,
5 wound care and other measures to relieve pain and suffering. Use oxygen, oral
6 suction and manual treatment of airway obstruction as needed for comfort. Patient
7 prefers no transfer: EMS contact medical control to determine if transport indicated".
8 "Full treatment (primary goal of prolonging life by all medically effective
9 means). Use treatments in Selective Treatment and Comfort Focused treatment.
10 Use mechanical ventilation, advanced airway interventions and cardioversion
11 if indicated".
12 (ii) "Limited additional interventions: Includes care described above. Use
13 medical treatment, IV fluids and cardiac monitor as indicated. Do not use
14 intubations, advanced airway interventions, or mechanical ventilation. Transfer to
15 hospital if indicated. Avoid intensive care unit if possible". "Selective treatment
16 (primary goal of treating medical conditions while avoiding burdensome
17 treatments) Use treatments in Comfort Focused treatment. Use medical
18 treatment, including antibiotics and IV fluids as indicated. May use noninvasive
19 positive airway pressure (CPAP/BiPAP). Do not intubate. Generally avoid
20 intensive care".
21 (iii) "Full treatment: Includes care described above. Use intubation, advanced
22 airway interventions, mechanical ventilation. Transfer to hospital if indicated,
23 includes intensive care unit". "Comfort focused treatment (primary goal is
24 maximizing comfort). Use medication by any route to provide pain and
25 symptom management. Use oxygen, suctioning and manual treatment of airway
26 obstruction as needed to relieve symptoms. (Do not use treatments listed in full
27 or selective treatment unless consistent with goals of care. Transfer to hospital
28 ONLY if comfort focused treatment cannot be provided in current setting.)"
29 (iv) "Additional orders (e.g. dialysis, etc.)"
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1 (h) A field titled "C. Antibiotics". This field shall provide an instruction
2 which reads "check one" and shall further provide three options for selection and one
3 area to record additional orders. The four items shall be labeled as follows:
4 (i) "No antibiotics. Use other measures to relieve symptoms".
5 (ii) "Use antibiotics if life can be prolonged".
6 (iii) "Determine use or limitation of antibiotics when infection occurs, with
7 comfort as goal. (Benefit of treatment should outweigh burden of
8 treatment)".
9 (iv) "Additional orders:"
10 (i) A field titled "D C. Artificially administered fluids and nutrition: (Always
11 offer food / fluids by mouth as tolerated)". This field shall contain the statement "The
12 administration of nutrition and hydration, whether orally or by invasive means, shall
13 always occur except in the event another condition arises, which is life-limiting or
14 irreversible in which the nutrition or hydration becomes a greater burden than benefit
15 to patient". "Medically assisted nutrition and hydration is optional when it
16 cannot reasonably be expected to prolong life, would be excessively burdensome
17 or would cause significant physical discomfort". This field shall provide an
18 instruction which reads "check one in each column" and shall further provide a
19 column listing three options for selection, a column listing two options for selection,
20 and one area to record additional orders. The six three items shall be labeled as
21 follows and contain the following text, respectively:
22 (i) A column shall list:
23 (aa) "No artificial nutrition by tube".
24 (bb) "Trial period of artificial nutrition by tube (Goal:__________)".
25 (cc) "Long-term artificial nutrition by tube (if needed)".
26 (ii) A column shall list:
27 (aa) "IV fluids (Goal:__________)".
28 (bb) "No IV fluids".
29 (iii) "Additional orders:"
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1 (j) A field titled "E. Other instructions: (May include additional guidelines
2 for starting or stopping treatments in sections above or other directions not addressed
3 elsewhere)".
4 (k)(j) A field titled "F D. Summary of goals" which shall comprise the
5 following two parts:
6 (i) An area providing an instruction which reads "check one" and further
7 providing the text "Discussed with" and the following two options for selection:
8 (aa) "Patient (Patient has capacity)".
9 (bb) "Personal health care representative (PHCR)".
10 (ii) An area providing an instruction which reads "check all that apply" and
11 further providing the text "The basis for these orders is:" and the following four
12 items for selection:
13 (aa) "Patient's declaration (can be oral or nonverbal)".
14 (bb) "Patient's personal health care representative (qualified patient Qualified
15 Patient without capacity)."
16 (cc) "Patient's advance directive, if indicated, patient has completed an
17 additional document that provides guidance for treatment measures if he/she loses
18 medical decision-making capacity".
19 (dd) "Resuscitation would be medically non-beneficial".
20 (ee) "Advance Directive dated" with a space to insert the date and
21 "available and reviewed".
22 (ff) "Advance Directive not available".
23 (gg) "No Advance Directive".
24 (hh) "Health care agent if named in Advance Directive:" with an area
25 to provide a name and phone number.
26 (ii) A field with the statement "This form is voluntary and the signatures
27 below indicate that the physician orders are consistent with the patient's
28 medical condition and treatment plan and are the known desires or in the best
29 interest of the patient who is the subject of the document".
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1 (l)(k) Fields A section to include fields for recording the name, signature,
2 and phone number of a physician. A field for the date indicating that a date and
3 signature are mandatory.
4 (m)(l) Fields, labeled "Mandatory," for recording the name and signature of
5 the patient or personal health care representative and the date of such signature
6 including an indication that the date and signature are mandatory.
7 (n)(m) A field stating "If personal health care representative, state
8 relationship and authority to act on behalf of patient". "PHCR relationship" with
9 a place to notate the relationship, a field stating "PHCR address" with a place
10 to note the address, and a field stating "PHCR phone number" with a place to
11 note the phone number.
12 (n) A field with last name, first name, middle name, and date of birth.
13 (o) A field titled "Directions for health care professionals" which shall consist
14 of three sections, labeled as follows, and state the following information,
15 respectively:
16 (i) A section labeled "Completing LaPOST" which shall state the following:
17 (aa) "Must be completed by a physician and patient or their personal
18 health care representative based on patient the patient's medical conditions and
19 preferences and medical indications for treatment".
20 (bb) "LaPOST must be signed by a physician and the patient or PHCR to
21 be valid. Verbal physician orders are acceptable with follow-up signature by
22 physician in accordance with Louisiana law from physician and verbal consent
23 may be obtained from patient or PHCR according to facility/community
24 policy".
25 (cc) "Use of the brightly colored original form is strongly encouraged.
26 Photocopies and faxes of signed LaPOST are legal and valid".
27 (ii) A section labeled "Using LaPOST" which shall state the following:
28 (aa) "Completing a LaPOST form is voluntary. Louisiana law requires
29 that a LaPOST form be followed by health care providers and provides
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1 immunity to those who comply in good faith. In the hospital setting, a patient
2 will be assessed by a physician who will issue appropriate orders that are
3 consistent with the patient's preferences".
4 (bb) "LaPOST does not replace the advance directive. When available,
5 review the advance directive and LaPOST form to ensure consistency and
6 update forms appropriately to resolve any conflicts".
7 (cc) "The personal health care representative is defined under R.S.
8 40:1159.4 and may execute the LaPOST form only if the patient lacks capacity".
9 (dd) "If the form is translated, it must be attached to a signed LaPOST
10 form in ENGLISH".
11 (aa)(ee) "Any section of LaPOST not completed implies full treatment for
12 that section".
13 (bb)(ff) "A semi-automatic external defibrillator (AED) should not be used
14 on a person who has chosen "do not attempt resuscitation" "Do Not Attempt
15 Resuscitation"".
16 (gg) "Medically assisted nutrition and hydration is optional when it
17 cannot reasonably be expected to prolong life, would be excessively burdensome
18 or would cause significant physical discomfort".
19 (cc) "Even if a patient chooses "no artificial nutrition by tube" or "no IV
20 fluids" or "trial period of artificial nutrition by tube," the administration of nutrition
21 and hydration, whether orally or by invasive means, shall always occur except in the
22 event another condition arises which is life-limiting and irreversible in which
23 nutrition and hydration by any means becomes a greater burden than benefit to
24 patient".
25 (dd)(hh)"When comfort cannot be achieved in the current setting, the person,
26 including someone with "comfort measures only Comfort focused treatment,"
27 should be transferred to a setting able to provide comfort (e.g. pinning of a hip
28 fracture)".
29 (ee)(ii) "A person who chooses either "comfort measures only Selective
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1 treatment" or "limited additional interventions Comfort focused treatment" should
2 not be entered into a Level I trauma system".
3 (ff)(jj) "A parenteral Parenteral (IV/Subcutaneous) medication to enhance
4 comfort may be appropriate for a person who has chosen "comfort measures only
5 Comfort focused treatment"".
6 (gg)(kk) "Treatment of dehydration is a measure which may prolong life. A
7 person who desires IV fluids should indicate "limited interventions Selective
8 treatment" or "full Full treatment"".
9 (hh)(ll) "A person with capacity or the personal representative (if the patient
10 lacks capacity) can revoke the LaPOST at any time and request alternative treatment
11 based on the known desires of the individual; or, if unknown, the individual's best
12 interests".
13 (ii)(mm) "Please see links on www.La-POST.org for "what my
14 cultural/religious heritage tells me about end of life care"".
15 (jj)(nn) "The duty of medicine is to care for patients even when they cannot
16 be cured. Physicians and their patients must evaluate the use of technology available
17 for their personal medical situation. Moral judgments about the use of technology to
18 maintain life must reflect the inherent dignity of human life and the purpose of
19 medical care".
20 (iii) A section labeled "Reviewing LaPOST" which shall provide the
21 following:
22 (aa) The statement: "This LaPOST should be reviewed periodically such as
23 when the person is transferred from one care setting or care level to another, or there
24 is a substantial change in the person's health status. A new LaPOST should be
25 completed if the patient wishes to make a substantive change to their treatment goal
26 (e.g. reversal of prior directive). When completing a new form, the old form must be
27 properly voided and retained in the medical chart. To void the LaPOST form, draw
28 a line through "Physician Orders" and write "void" "VOID" in large letters. This
29 should be signed and dated".
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1 (bb) A chart titled "Review of this LaPOST form" consisting of four columns
2 which are titled as follows:
3 (I) "Review date and time".
4 (II) "Reviewer".
5 (III) "Location of review".
6 (IV) "Review outcome". Each row in this column shall contain the following
7 two options for selection:
8 (aaa) "No change".
9 (bbb) "Form voided and new form completed Voided and New Form
10 Completed".
11 * * *
12 Section 2. This Act shall become effective upon signature by the governor or, if not
13 signed by the governor, upon expiration of the time for bills to become law without signature
14 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
15 vetoed by the governor and subsequently approved by the legislature, this Act shall become
16 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 Engrossed 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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Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Health and Welfare to
the original bill
1. Makes technical changes to the statutory requirements for the LaPOST form.
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words in boldface type and underscored are additions.