Background

The COVID-19 pandemic disproportionately affects older individuals and those with underlying medical conditions. Residents of long-term care facilities are particularly affected due to the congregate living environment that can increase risk of exposure to COVID-19 and the high rate of residents who are older and/or have underlying medical conditions.

Residents have a right to receive care consistent with their preferences. In light of COVID-19, each facility should prospectively confirm residents' treatment preferences, develop care plans and obtain requisite orders to reflect residents' goals, values and preferences, and put policies and procedures in place to support resident treatment wishes being recognized and honored. Facilities should recognize that residents have a right to create advance care planning documents but cannot be required to do so.  Facilities should ensure that information is effectively communicated to residents and decision makers and provide auxiliary aids and services to residents with disabilities as needed to facilitate communication.

Recommendations

The California Department of Public Health (CDPH) recommends that skilled nursing facilities (SNFs) take the following proactive steps with all residents:

• Ensure that all residents/decision makers are informed about COVID-19 and the higher risk of severe illness and death from COVID-19 for older persons and those with serious illness.
• Inform all residents/decision makers of possible treatment options for those who become seriously ill from COVID-19, including those treatment options that are available in the facility.
• Make residents/decision makers aware that cardiopulmonary resuscitation (CPR) is the default treatment for cardiac arrest and will be started unless there is an existing valid "do not resuscitate" (DNR) order documented in the medical chart or POLST form.
• Confirm with the resident or their decision maker the resident's current preferences for treatment in the event of severe COVID-19 symptoms. Record their preferences in the resident's medical record with appropriate orders, using a POLST if appropriate and, if possible, an advance health care directive (AHCD).
• Review all residents' existing advance care planning documents, including AHCDs, POLST forms, and other records documenting a resident's specific treatment preferences.
• Remind staff that a POLST form is only appropriate for residents who are seriously ill or nearing end of life. A POLST form is always voluntary for the resident and cannot be required as a condition of admission. If a POLST form is not appropriate, consider use of Preferred Intensity of Treatment (PIT) or Preferred Intensity of Care (PIC) forms and regular code status and other treatment preference orders entered in the facility chart.
• Confirm that each resident's existing treatment orders reflect the current wishes of the resident or their decision maker (if appropriate), in light of COVID-19.
• Create a treatment plan and obtain medical orders that reflect resident preferences, including whether the resident wants to be transferred to an acute care hospital for treatment of severe COVID-19 symptoms.
• Consider developing a telehealth program to support advance care planning conversations and rapid virtual access for residents and families to community and hospice palliative care services.

CDPH recommends that SNFs take the following proactive steps with all residents who test positive for COVID-19:

• Develop a plan to assess all residents with COVID-19 to determine whether transfer to an acute care hospital is medically indicated and desired by the resident.
• If a resident's needs cannot be met at the SNF or if transfer to the hospital is requested by the resident/decision maker, implement a plan to communicate to the receiving hospital the resident's COVID-19 status, treatment preferences, and reason for transfer.
• Residents with POLST forms indicating DNR/Comfort-Focused Treatment, or DNR/Selective Treatment with the "Request transfer to hospital only if comfort needs cannot be met in current location" box checked, should not be sent to the hospital except where care needs cannot be met at the facility, unless the resident or their decision maker makes a contrary request.  POLST forms are meant to give guidance when the resident is unable to personally make decisions.  When a resident is able to make decisions, the facility should consult with the resident to determine the appropriate course of action.
• Ensure that nursing staff and medical providers, including the facility medical director, are familiar with the use of comfort measures and medications for severe respiratory symptoms, including prompt initiation and titration of opioids and benzodiazepines. Ensure that these medications are available and administered appropriately for residents who choose to receive comfort-focused treatment for severe COVID-19 illness.
• Explore options, including community palliative care and hospice, to increase palliative care capacity.

Resources to support advance care planning, including POLST and AHCD forms, sample SNF POLST policies, best practices and Health Care Decision Aids for CPR, Ventilator, Artificial Hydration, and Feeding Tubes, are available at no cost from the Coalition for Compassionate Care of California's website.

Sincerely,

Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director