The Indiana POST* Program

*Physician Orders for Scope of Treatment


The Indiana POST Program is a new advance care planning tool that helps ensure treatment preferences are honored. It is designed for patients with serious illness. Preferences for life sustaining treatments including resuscitation, medical interventions (e.g., comfort care, hospitalization, intubation, mechanical ventilation), antibiotics, and artificial nutrition are documented as medical orders on the POST form. It must be reviewed and signed by a physician to be activated. This form transfers throughout the health care system and the orders are valid in all settings.

Official Indiana POST Form

The official Indiana POST form can be found on the Indiana State Department of Health website at http://www.in.gov/isdh/25880.htm. It is strongly recommended that the form be printed on Astrobrights Pulsar Pink 65 lbs (cardstock) or an equivalent. Black and white versions as well as photocopies and faxed versions are considered valid.

Frequently Asked Questions

What is the POST form?

The Indiana POST form is a standardized form containing orders by a treating physician based on a patient's preferences for end-of-life care. The form provides physician orders regarding CPR-code or no code status; level of medical intervention (comfort measures, limited additional interventions, or full intervention); use of antibiotics (for comfort only or full treatment); and use of medically administered nutrition. The comfort measures level stipulates: "Patient prefers no transfer to the hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location." Use of this form should lead to better identification and respect of patients' preferences for treatment at life's end. The Indiana POST form is based on the POLST (Physician Orders for Life-Sustaining Treatment) Paradigm Program (www.polst.org).

Who should have a POST form?

Unlike an advance directive, which is appropriate for all adults, the POST form is specifically intended for seriously ill persons with advanced chronic progressive illness, advanced chronic progressive frailty, or terminal conditions. It is also appropriate for patients who are unlikely to benefit from cardiopulmonary resuscitation. Use of the POST form is typically not appropriate for persons with early stage progressive illness or functionally disabling problems who have many years of life expectancy. 

Is a POST form required for all patients?

No.  Completion of the POST form is voluntary, but it is encouraged for seriously ill patients so that all participating in a patient's care can readily know the medical treatment the patient wishes to undergo at the end of life. Individuals are encouraged to complete a POST form when their physician would not be surprised if the patient died within a year. Completion of POST forms is highly recommended for hospitalized patients being discharged to nursing homes or to their own home with hospice or home health care. Completion of POST forms is also highly recommended for nursing home residents either at the time of admission to nursing homes or during quarterly care planning. However, the use of a POST form is always voluntary.

Which form should the patient complete? The POST form? The Living Will? The Health Care Power of Attorney form?

Each form has a different purpose. The Indiana Living Will Act contains both a Living Will and a Life Prolonging Procedures Declaration. These forms are the most restrictive and only go into effect if the patient has lost decision-making capacity and a physician certifies that death will occur within a "short time." If the patient wants to be clear about the type of treatment he/she will receive under these limited conditions, then the patient should complete either a Living Will or a Life Prolonging Procedures declaration. These declarations can be found at IC 16-36-4.

The Indiana Power of Attorney form contains the legal paperwork to appoint an attorney in fact for health care. This individual is given legal authority to make decisions for the patient when he/she has lost decision-making capacity. All patients are strongly encouraged to complete a power of attorney for health care form. More information about this form can be found at IC 30-5-4 and IC 30-5-5-16 and 17.  Anyone can have a Living Will or a Power of Attorney, regardless of health status.

The Indiana POST form is recommended for patients who are seriously ill and whose death within a year would not be a surprise to the patient's physician. Because the POST form is a medical order, of the three forms, the POST form is the one that is most likely to ensure that the patient receives the treatment that he/she wants. For patients with advanced chronic progressive illness, advanced frailty, or terminal conditions, it would be entirely appropriate for the patient to complete all three forms: a living will, power of attorney for health care, and a POST form. The completion of these forms maximizes the possibility that the patient will have his/her end-of-life treatment preferences known and respected. In addition to completing the forms, the patient needs to be sure to discuss his/her preferences for end-of-life treatment with the person that he/she designated as his/her legally authorized representative. The POST form contains a health care representative appointment section on the back of the form for patients who have not previously identified a health care power of attorney.

Does the patient need a DNR order if he/she has a POST form?

No, the patient does not need a separate DNR order.  The Indiana POST Act establishes the Indiana POST form as a legally recognized means of "Do Not Resuscitate" identification In Section A, the POST form includes either a full resuscitation or Do Not Attempt Resuscitation (DNR) order. Because the POST form remains with the patient, a POST form will suffice as a DNR order for patients who are confined and who always have the POST form readily available. However, the Indiana Out-of-Hospital DNR Order form (CODE) is still legally valid.

Does a physician need to sign the POST form?

Yes. The POST form is a physician's order and must be reviewed and signed in Section E by a licensed physician. The POST cannot be signed by a nurse practitioner or physician assistant.

What if the treating physician does not want to sign a POST form but the patient or incapacitated patient's legal agent wants one?

Some physicians may be reluctant to sign a POST form because they are unfamiliar with the
patient and/or with the ethical and legal issues addressed by the form. There are several options in this situation: 1) other health care professionals can educate the physician regarding the legal protection the form provides to the patient, legal agent, physician, and health care facility when validly completed; 2) Indiana law allows any treating physician to sign a POST form; or 3) the patient or patient's legal agent can transfer the patient's care to another treating physician who is willing to complete a POST form for the patient.

Can a social worker, nurse or other health care professional prepare the POST form?

Yes. Social workers, nurses, and other health care professionals designated by the treating physician can prepare the form with patients or their legally appointed representatives. The person preparing the form should sign his/her name in the space provided for the preparer on the back of the form. To activate the form, a physician must review it to confirm the orders are reasonable and medically appropriate for the individual before signing it.

Should the POST form be completed or voided without a conversation with the patient or his/her representative?

No. The POST form should not be completed, changed, or voided unless there is a conversation with either the patient or, if the patient lacks capacity, his/her legally authorized representative. The purpose of the form is to ensure that the patient's wishes for care at the end of life are followed so a conversation must take place.

When does the POST form have to be reviewed?

The POST form should be reviewed when the patient is transferred from one health care facility to another or when there is a change in his or her medical condition.

What if a patient or legally authorized representative changes his/her mind about the preferences documented on the POST form?

Requests for alternative treatment should be honored as a patient can change his or her mind at any time. The representative can revoke the POST form only if the patient lacks decisional capacity. If a patient or representative wishes to revoke the POST form, this can be done writing these wishes down with a signature and date, physical cancellation or destruction of the form, or a verbal expression of the intent to revoke. If this happens, the change takes effect when it is communicated to the health care provider. The health care provider is responsible for notifying the treating physician, who must then document information about the revocation including the time, date, and place of revocation and when they first learned of the revocation in the patient's medical record. The POST form should be canceled by making a note in the patient's medical record. The patient's health care providers and the physician who initially signed the POST should be notified as well.

Should the POST form be used to guide daily care decisions?

Yes. For example, the completed POST form should be used to guide decisions regarding the placement of feeding tubes, the use of antibiotics to treat pneumonia, and the provision of other treatments for the patient. The POST form is not just for patients in cardiac arrest.

Are health care providers required to comply with the orders on the POST form?

Yes. The POST form is based on the patient's preferences or on the decisions of the patient's legally authorized representative, which should reflect the qualified patient's preferences (if known) or the best interest of the qualified patient if his or her preferences are unknown. The medical orders included in a POST form are effective in all settings. A health care provider shall comply with a declarant's POST form that is apparent and immediately available to the provider. However, a health care provider is not required to comply with a patient's POST form if the provider: a) believes the POST form was not validly executed under Indiana law; b) believes in good faith that the POST form has been revoked by the patient or their legally authorized representative; c) believes in good faith that the patient or their legally authorized representative has made a request for alternative treatment; d) believes it would be medically inappropriate to provide the intervention on the patient's POST form; or e) has religious or moral beliefs that conflict with the POST form orders. If the health care provider is unable to implement or carry out the orders because of their own personal religious or moral beliefs, they are required to coordinate the transfer of care for the patient to another health care provider who is able to carry out the orders. If this is not possible, further direction is provided in the Indiana POST Act regarding the appropriate next steps.

The Indiana POST Act provides legal protection for health care providers who comply with the orders on POST forms. In the law, health care providers are not subject to civil or criminal liability for good faith compliance with or reliance upon POST forms.

Where should the original POST form be kept?

The POST form is the personal property of the patient. In most circumstances, the original POST form should be kept with the patient. If the patient resides at home, the POST form should be kept with the patient's medication or on the refrigerator. Family members and caregivers should know where the form is located. Health care facilities should keep the POST form as the first page in a person's paper medical record and in a prominent location in a person's electronic medical record unless otherwise specified in the health care facility's policies and procedures. If the patient is a nursing home resident, the nursing home may choose to keep the original when the patient is transferred to a hospital for admission and send a copy of the original POST form with the patient.

Educational Resources

History

The Indiana Patient Preferences Coalition (IPPC) is a coalition of professionals in health care, ethics, law, and senior services committed to honoring patient treatment preferences. The group first formed in August 2010 to explore the development of the Indiana version of the POLST Paradigm (www.polst.org). Legislation was introduced by Representative Tim Brown, MD (R - Crawfordsville) in 2012 and reintroduced in 2013. HB 1182 passed the house unanimously (95 to 0) and was passed nearly unanimously in the Senate (48 to 1) before being signed into law in May 2013. The Indiana POST will become legally valid throughout the state of Indiana on July 1, 2013.

Research

Although the POST Program was originally designed as a clinical innovation, research has been part of the POST program since its inception. Focus groups led to the initial development of a medical treatment coversheet1 and subsequent research led to revisions that simplified the language and format.2 The POST program is frequently used in the nursing facility and hospice setting.3-6 Emergency medical personnel report that the POST form is helpful in guiding treatment decisions.7 Unlike most traditional living wills, that the POST program alters the kind of treatments people receive near the end of life so that it is consistent with their preferences. Unlike traditional code status orders which narrowly focus on decisions about resuscitation, POST permits individualization of treatment goals to better reflect the myriad of decisions patients face in the last year of life.3-5 In a large, federally-funded multi-state study of POST form use in nursing facilities, residents with POST form orders were significantly more likely to have treatment preferences documented as orders in their medical records. Residents with POST form orders for comfort measures only were 67% less likely to be hospitalized than residents with orders for full treatment.6 Treatments provided were highly consistent with POST form orders for resuscitation (98%), medical interventions (92%), antibiotic use (93%) but less so for feeding tube use (64%).8

1Dunn, Schmidt, Carley, Donius, Weinstein, & Dull (1996)
2Dunn, Nelson, Tolle, & Tilden (1997)
3Hickman, Tolle, Brummel-Smith, & Carley (2004)
4Hickman, Nelson, Moss, Hammes, Terwilliger, Jackson, & Tolle (2009)
5Hammes, Rooney, Gundrum, Hickman, & Hager (2012)
6Hickman, Nelson, Perrin, Moss, Hammes, & Tolle (2010)
7Schmidt, Hickman, Tolle, & Brooks (2004)
8Hickman, Nelson, Moss, Tolle, Perrin, & Hammes (2011)

Supporting Organizations

The following organizations provided public support for HB 1182 to create the Indiana POST Program.

Indiana State Medical Association
Indiana Academy of Family Physicians
Indiana Medical Directors Association
Indiana Osteopathic Association
Indiana Hospital Association
Indiana Chapter of the American College of Emergency Physicians
Indiana State EMS Commission
Indiana Health Care Association
Indiana Hospice and Palliative Care Organization
Indiana Association for Home and Hospice Care
Indiana Association for Area Agencies on Aging*
Indiana Geriatrics Society
CICOA Aging & In-Home Solutions
Indiana AARP
Indiana Alzheimer's Association
Indiana Fire Chiefs Association
Center for Parish Nurses
Indiana Chapter of the National Academy of Elder Law Attorneys
Indianapolis Patient Safety Coalition
St. Mary's Health, Evansville
IU Health Systems
IU Health Goshen
Community Health Network
Lutheran Hospital of Indiana
Memorial Hospital and Health Care Center

Contact Information

The Indiana Patient Preferences Coalition (IPPC) is a volunteer group of stakeholders. If you have a question about the IPPC or Indiana POST Program and are a healthcare professional affiliated with one of the groups listed above, please first contact that group. Otherwise, you are welcome to contact one of the following: