OBJECTIVE: To assure that patient welfare is protected and that appropriate actions are taken when decisions related to limitations in treatment are made.

POLICY:

1. The Limitations of Treatment policy provides instruction and guidance to health care providers about decisions regarding specific treatment limitations.
2. On admission, all patients will have a code status order and/or limitations of treatment (LOT) order placed.
3. All pre-printed orders will have Code Status and LOT selections
4. Code Status orders will consist of the following:
1. Full Code
2. DNAR
5. Staff who has personal, morale or religious conflicts with the limitation of treatments should notify their supervisors and ask for reassignment. 
6. Supervisors shall not force any staff member to comply with any limitation of treatment orders that the staff member is in personal conflict with.
7. Staff will place a blue alter band with the handwritten limitation of treatment indicated by “LOT”.
8. A Limitation of Treatment  order refers to but not limited to the following treatments:
1. Anti-Arrhythmics
2. Cardiac Pacemakers
3. Pressors
4. Elective Endotrachael Intubation
5. Mechanical Ventilation, including C-PAP and B-PAP
6. Defibrillation
7. Renal Dialysis
8. Antibiotics
9. Artificial Hydration
10. Nutrition, Enteral or Parenteral
11. Transfer to ICU
9. Patient care personnel should notify the responsible physician(s) if approached by the patient/surrogate regarding limitations in treatment.
10. Consent to the Limitation of Treatment status may be revoked at any time by the patient as long as they have decision-making capacity, or by their surrogate should the patient not be able to represent him or herself.
11. When a change in physician service occurs, a Limitation of Treatment order should be maintained without disruption unless revoked by the patient or their surrogate in the event of patient incapacity.
12. If Limitation of Treatment is no longer indicated, or has been rescinded, then an order should be written at the time of transfer rescinding the Limitation of Treatment order, accompanied by documentation as to why.
13. Out of Hospital Limitation of Treatment, that come with the patient on admission to the hospital, should be respected and automatically applied until the patient or their surrogate revokes them.
14. When Out of Hospital Limitation of Treatment   orders come with the patient to the hospital this status should be reconfirmed with the patient or their surrogate and a new Limitation of Treatment order should be written and co-signed by the attending physician.
15. Limitation of Treatment status should terminate upon discharge from the hospital unless otherwise specified by a physician’s order
16. Limitation of Treatment status will be communicated to the facility and healthcare providers who will be assuming treatment responsibility for the patient following discharge.
17. When a patient is to undergo operative, diagnostic, or therapeutic procedures that place them at risk for cardiac or pulmonary arrest, the physician doing the procedure should clarify with the patient and/or surrogate the meaning of the Limitation of Treatment order in the context of balancing the specific risk(s) and potential benefits of the procedure(s).
18. The medical record should then reflect that the patient’s Limitation of Treatment status has subsequently been reviewed, retained, and/or modified prior to undergoing the procedure.
19. In some cases, performance of a procedure may require that intubation, ventilatory support, or other life system support be provided in order to complete the procedure safely in a patient with a Limitation of Treatment order (e.g., support for a patient undergoing a procedure that requires deep sedation or anesthesia). 
20. Although such a process would not normally be considered resuscitation, permission to provide such support should be obtained by the procedural physician or the anesthesiologist/anesthetist at the time of obtaining consent for the procedure.
21. Conflicts or disagreements regarding Limitation of Treatment orders should be resolved before the order is written.  Assistance may be obtained by contacting Social Services, Pastoral Care, or the Clinical Ethics Consult Service.  You may reach the ethicist on call through the hospital operator or by calling the Center for Health Ethics (882-2738) during normal working hours.
22. Advance Directives serve as a general guideline regarding the patient’s wishes at the end of life and should be offered to the patient if they have decision-making capacity as part of the Limitation of Treatment decision-making process.
23. When the patient reaches the patient care area, the nursing staff is responsible for clarifying and indicating any documented limitations of treatment by placing a blue alert band on the patient. 
24. Each patient that has current physician orders in their medical record that delineate limitations of treatment will have those choices documented by handwriting on the blue alter band with the indication of “LOT”.
25. Changes in the patient’s clinical status may require reevaluation of the Limitation of Treatment order.
26.  Changes in Limitation in Treatment status will be written as a new order in the medical record.

PROCEDURE:

Responsibilities of Physician (Attending, Fellow or Resident)

1. Review Advance Directive in the patient’s chart
2. Evaluate medical condition of the patient
3. Educate the patient/surrogate about the consequences of the Limitation of Treatment order
1. Document Limitation of Treatment on the pre-printed physician order sheet.
2. Other limitations should be listed separately in the general physician orders
4. Initial Limitation of Treatment orders must be written. 
5. The House Officer may write orders after consultation with the Attending Physician.  That conversation must be documented in the progress notes or on the Limitation of Treatment Order Form. 
6. The Attending Physician should cosign initial Limitation of Treatment orders written by the House Officer or any subsequent modifications to the orders within 48 hours.
7. Document the following in the progress notes or on the Limitation of Treatment Order Form:
1. Clinical indications for the order and prognosis
2. Acknowledge the presence or absence of the patient’s written advance directive and a brief notation as to the directives that place limitations on treatment
3. Discussions with the patient or their surrogate, noting the patient’s values, beliefs, and preferences pertaining to any Limitation of Treatment.
4. Discussion with the attending physician if a resident or fellow writes the order.

Staff

1. The Unit clerk/Nurse needs to Transcribe the order
2. The Unit clerk/Nurse will note the order and accomplish the following:
3. Enter the Code Status Order into PowerChart by selecting Limitations of Treatment from the Care Sets order group.
4. Select the indicated Limitation of Treatment indicated by the physician on the pre-printed order form
1. Limitations of Treatment
2. Other Limitations of Treatment
3. Transcribe the order
4. Place a piece of blue tape on the side of the order sheet where the physician order is written as well as on the preprinted LOT order sheet so that it can be easily found.
5. Place a blue sticker on the front cover of the hard chart indication LOT to match the color of the armband.
5. Those units who do not have PowerChart will:
6. Transcribe the order
7. Place a piece of blue tape on the side of the order sheet where the physician order is written as well as on the preprinted LOT order sheet so that it can be easily found.
8. Place a blue sticker on the front cover of the hard chart indication LOT to match the color of the armband.

3.   The Unit clerk will give the nurse a blue armband for them to place on the patient.

Registered Nurse - Acknowledge the Limitation of Treatment order by signature at the time it is written.

Nursing Staff

1. Apply a blue wristband, noting in handwriting “LOT” on the blue alert band.
2. Should it become necessary to remove the identification band from the original site, the person removing the band will be responsible for immediately replacing the band, or relocating it as necessary. 
3. If unable to place the band on an extremity due to complications, the band(s) may be placed on the urinary catheter as a last resort.
4. Inform the physician of changes in the patient’s condition and any requests for revocation of the Limitation of Treatment order by the patient/surrogate.

Physician/Nursing Staff

1.   Order expiration and review:

1. The Limitation of Treatment order can be revoked at any time if clinically indicated or if requested by the patient/surrogate.
2. In such a case, the blue LOT band will be removed and discarded.

Key Content Expert: Chair, Patient Rights and Organizational Ethics

 Approved:

 _____________________________________                        7/1/08
                                        
Anita M. Larsen, Interim Chief Operating Officer                         Date
University of Missouri Health Care