The Michigan Physician Orders for Scope of Treatment (MI-POST) is now available for qualifying patients throughout the entire State of Michigan.
Below is what Healthcare Team members need to know about the MI-POST, including:
- What Healthcare Team members need to know about the MI-POST
- How the MI-POST is different than an Advance Directive/Durable Power of Attorney for Healthcare?
- How the MI-POST is different from a Michigan Do Not Resuscitate (DNR) order?
- Frequently Asked Questions
- Additional Resources
What Healthcare Team members need to know about the MI-POST
What is the MI-POST?
The MI-POST is intended for adult patients who have advanced frailty or serious illness resulting in a shortened life expectancy of a year or less. It is an optional, two-page, two-sided out of hospital medical order that is part of the advance care planning process that directs what care the patient should receive if they require medical attention. The MI-POST is executed by the patient’s attending physician, nurse practitioner, or physician's assistant in collaboration with the patient (or the patient’s Patient Advocate/Guardian when applicable). The MI-POST document is a valuable tool to protect a patient’s rights and preferences for the care they receive.
“Unlike other advance care planning directives, the MI-POST is effective immediately and aims to put the patient’s decisions into a medical order set that should be followed at any Michigan healthcare facility, as well as by first responders. Other advance care planning directives do not allow for this” explained Stephanie VanSlyke, Sr. Coordinator of Advance Care Planning and Ethics for Munson Medical Center and Michigan representative for the National POLST organization.
It is important for Healthcare Team members to know that patients may present to a MHC facility with a MI-POST and that this medical order. It serves as a communication tool for Healthcare Teams when patients need care within a hospital and it should be used as a guide for facilitating care plan discussions and decisions. If a hospitalized patient wishes to extend their DNR order beyond the hospital walls, discharge planning should include the completion of a MI-POST (or Michigan DNR) order. Without this, EMS will be obligated to perform CPR.
How the MI-POST is different than an Advance Directive/Durable Power of Attorney for Healthcare?
Here are the main differences between an Advance Directive/Durable Power of Attorney for Healthcare and the MI-POST.
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|
MI-POST |
Advance Directive/Durable Power of Attorney for Healthcare |
|
Patient population |
Adult patients who have advanced frailty or serious illness resulting in a shortened life expectancy of a year or less. |
Competent adults, regardless of health status. |
|
Document Intention |
Identifies what care the patient should receive if they require medical attention.
|
Identifies who the patient has designated as their patient advocate(s). May, or may not, outline wishes about medical treatments, CPR or life-sustaining treatment preferences. |
|
Standard Form |
YES, standardized by State. Can be found under forms (#4950) |
NO, many varieties May be called a DPOAH, an AD or a Patient Advocate Designation (when valid they are all treated synonymously). |
|
Who Completes it? |
The patient’s attending physician, nurse practitioner, or physician assistant. |
The patient |
|
Signature Requirements |
The patient’s attending physician, NP, or PA The patient (or the patient’s Patient Advocate/Guardian when applicable). |
The patient Two witnesses The patient advocate(s), upon acceptance.
|
|
Witnessing Requirements |
NO |
YES Witnesses must be at least 18 years of age and cannot be any listed patient advocates, family members, healthcare or mental health facility employees where the patient receives care, or employee of a life or health insurance provider. |
|
When does it go into effect? |
Effective Immediately |
Only when activated. Activation requires a capacity determination by two physicians or one physician and a licensed psychologist. |
|
Actionable by EMS? |
YES |
NO |
|
Interpretation Ease |
Easily interpreted Based on current state of health |
Sometimes vague Hypothetical in nature |
How the MI-POST is different from a Michigan DNR order?
Michigan also has an out of hospital Do Not Resuscitate (DNR) medical order under the 1996 Do Not Resuscitate Procedure Act. Below is how the MI-POST is different from a Michigan DNR order.
|
|
MI-POST |
Michigan DNR |
|
Patient population |
Adult patients who have advanced frailty or serious illness resulting in a shortened life expectancy of a year or less. |
Adults or minors (less than 18 years of age unless emancipated) with an advance illness or significant functional impairment that is not reversible and anticipated to progress toward death despite therapies or modulation |
|
Standard Form |
YES, standardized by State. Printed on PINK card stock paper. Photo copies of the original is acceptable |
NO, State only provides guidelines for what needs to be on the form. Printed on standard white paper. Photo copies of the original is acceptable |
|
Signing Authority |
The patient’s attending physician, NP, or PA. |
The patient’s attending Physician Cannot be a NP or PA. |
|
Signature Requirements |
The patient’s attending physician, NP, or PA. The patient (or the patient’s Patient Advocate/Guardian when applicable). |
The patient’s attending Physician The patient (or the patient’s Patient Advocate/Guardian when applicable). |
|
Witnessing Requirements |
NO |
YES 2 witnesses: Witnesses must be 18 years of age or older, at least 1 of whom is not a spouse, family member or presumptive heir to the patient.
|
|
When does it go into effect? |
Effective Immediately |
Effective Immediately |
|
Actionable by EMS? |
YES |
YES |
|
Medical Orders |
May include Attempt CPR Directs care beyond CPR such as full, selective or comfort focused interventions.
|
Only directs that CPR be withheld |
It is important to note that a patient should only have one or the other completed; not both. If a healthcare professional is aware that the patient has both, they should comply with the most recent one. Additionally, both are:
- Applicable immediately.
- Actionable by EMS personnel.
- Easily interpreted and based on the individual’s current state of health.
Healthcare Team Frequently Asked Questions
How do I know if a patient has a MI-POST completed?
If a patient within the MHC System has completed a MI-POST and provided a copy to the MHC System, it can be found in the patients EMR under the Directives folder in Clinical Notes. It will be scanned under the name “POST/DNR”.
Where do I get a MI-POST if a patient and their healthcare provider would like to complete one?
If a physician, nurse practitioner, or physician's assistant feels their patient may benefit from a MI-POST, you can find a blank MI-POST Order here and the accompanying MI-POST Patient and Family Information Sheet here. Both are a necessary part of the order and completion instructions can be found here.
What do I do with a MI-POST once completed?
The original MI-POST is the property of the patient and should stay with the patient at all times. A patient should be instructed to place it on their refrigerator at home or in the designated location of the residential facility where the patient lives because EMS personnel are trained to look there. It is strongly recommended that a copy be provided to the hospital and uploaded into the patient’s electronic medical record.
How do I know which medical order is most appropriate to use?
Some patient living with life limiting illness or disease, such as patients requiring hemodialysis, CHF, or even certain cancers can have many life years left but have strong preferences against receiving CPR. Given their life-limiting illness, they many only want CPR withheld but prefer all other aspects of medical care. In these cases, the Michigan DNR order would be most appropriate.
Some patients are more frail or have difficulty with day to day actives who do not want to go through several medical procedures or care for a chance of living longer and they wish to withhold certain types of medical care beyond CPR alone. Others find that some things, like feeding tubes or mechanical ventilation, are very hard on their quality of life. In these cases, the MI-POST order would be most appropriate.
If a patient has a Michigan DNR order (or MI-POST) indicating they do not want CPR attempted, why are they a Full Code in the hospital?
Out of hospital medical orders do not serve as in hospital medical orders. Because a patient can change their mind at any time and some medical procedures, such as a cardiac cath or surgery, may necessitate a Full Code order, medical orders written in a hospital are to be based on each patient encounter and circumstance. The Michigan DNR order/MI-POST should serve as a communication tool when having a code status conversation with a patient. If a patient is unable to participate in a code status conversation and they have a valid DNR/MI-POST order, the Healthcare Team should look to these orders to provide insight into the patient’s prior treatment decisions.