Ala. Admin. Code r. 420-5-19-A3
ALABAMA ORDER FOR PEDIATRIC PALLIATIVE AND END OF LIFE (PPEL) CARE
______________________________________________________
Qualified Minor’s Full Name (PRINT) and Date of Birth
Instructions: Once executed by the representative, signed by the physicians, and entered into the medical record of the Qualified Minor by the attending physician, this order becomes the medical order for all health care providers with respect to the extent of use of emergency medical equipment and treatment, medication, and any medical interventions available to provide palliative and supportive care to the qualified minor.
The representative must complete and execute Sections 1 and 3. ONCE THESE SECTIONS ARE COMPLETED AND EXECUTED, the attending physician should sign Sections 1 and 2. Once a second physician has signed Section 2, enter the executed directive into the medical record of the Qualified Minor, which then becomes the PPEL Order.
The attending physician may assist the representative(s) with completing this document. After all sections are completed and signed, the attending physician enters the entire completed form into the medical record of the qualified minor. The physician orders will be generated from a PPEL Order entered into the Qualified Minor’s medical record.
This form does not supersede or nullify any internal requirements that a health care facility may require for physician’s orders to be entered in the health care facility’s medical records.
Note: The representative is responsible for updating the form if circumstances or the wishes of the representative change.
Section 1. Medical Orders
A physician may be sought to assist in completing this section after discussion with and in collaboration with the parent(s) or representative
A. Medical orders that, upon execution by the
representative, signing by the physicians, and entering
into the medical record, become the physician orders:
1. The extent of emergency medical equipment and treatment, medication, and any medical interventions available to provide palliative and supportive care. (Life sustaining treatment does not include the administration of medication or the performance of any medical treatment where, in the opinion of the attending physician, the medication or treatment is necessary to provide comfort or to alleviate pain.) (See Section 22-8A-3 (10), Code of Alabama)
(ATTACH ADDITIONAL PAGES AS NECESSARY):
3. The extent of the use of any other technological or medical interventions available to provide palliative and supportive care (ATTACH ADDITIONAL PAGES AS NECESSARY):
a)____________________________________________________________________
b)____________________________________________________________________
c)____________________________________________________________________
B. Patient Goals and Medical Conditions: (What are the Qualified Minor’s overall medical conditions and the representative’s treatment goals?)
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________ __________________
(Signature of Attending Physician) (Date)
Section 2. Physician Certification of Terminal Illness or Injury
I certify that I am qualified by experience in making a terminal illness or injury diagnosis, and based on my examination of this patient, have determined that the patient’s death is imminent or that the patient’s condition, to a reasonable degree of medical certainty, is hopeless unless the patient is supported through life sustaining procedures.
_________________________________ __________________
(Signature of Attending Physician) (Date)
I certify that I am qualified by experience in making a terminal illness or injury diagnosis, and based on either my examination of this patient or review of their medical record, and have confirmed that the patient’s death is imminent or that the patient’s condition, to a reasonable degree of medical certainty, is hopeless unless the patient is supported through life sustaining procedures.
_________________________________ __________________
(Signature of Attending Physician) (Date)
Section 3. Declaration by Representative of Qualified Minor:
The representative must initial at each blank:
____I am the parent whose medical decision-making rights have not been restricted, or a legal guardian of the qualified minor, or a person acting as a parent of the qualified minor according to Alabama Code §30-30B-102.
____The attending physician(s) and I have discussed the treatment goals and objectives about end of life care and I agree that the medical orders in Section 1 reflect my directions about the qualified minor's medical care; and, upon execution, signing by the physicians, and entering into the medical record, shall become the physician orders.
____I consent to the medical orders becoming the physician orders in Section 1.
____I understand that either I or the qualified minor can revoke this PPEL Order at any time by verbally revoking the PPEL Order or by an act demonstrating the intent to revoke the PPEL Order.
____I understand that any health care provider or health care facility acting within the applicable standard of care who is signing, executing, ordering, or attempting to follow this Order for PPEL Care shall not be subject to criminal or civil liability.
____I understand that resuscitative measures may be withheld from the qualified minor based upon the instructions provided in this PPEL Order.
By executing this PPEL Order, I am certifying under penalty of perjury that the information contained in this PPEL Order is correct to the best of my knowledge. I am directing the attending physician to enter this form into the medical record, which shall make this a valid PPEL Order.
*Signatures of Representative(s) Date
________________________________ ___________________
________________________________ ___________________
________________________________ ___________________
________________________________ ___________________
*Use more lines for more signatures, if necessary.
Instructions for completing this form:
I. Directions for Health Care Professionals.
A PPEL Order contains instructions for health care providers (individual professionals, for example, physicians, nurses, and emergency medical technicians) only for the use of emergency medical equipment and treatment, medication, and any medical interventions available to provide palliative and supportive care to be provided to that qualified minor in a licensed health care facility (for example, hospitals and nursing homes). The form must be signed by two separate physicians acknowledging that the minor has been diagnosed as either terminally ill or injured, before it is valid.
II. Completing the PPEL Order Form.
It is the intent that an adult with authority over medical care decisions for the qualified minor (parent, legal guardian, or other adult acting as the parent of the minor) has considered the various medical care options as outlined in the form, has had conversations or assistance from the attending physician where appropriate or both, and has had the opportunity to consult with other professionals (for example, attorneys and clergy) for assistance in completing the form. As a result of these conversations or assistance or both, the adult individual indicates on the form the emergency medical equipment and treatment, medication, and any medical interventions available to provide palliative and supportive care to the qualified minor.
III. Using the PPEL Order Form.
If the minor's condition changes and time permits, the representative should be contacted by a facility or the attending physician to assure that the form is updated as appropriate.
If any section has not been completed, then the health care provider should follow other appropriate methods to determine treatment.
An automated external defibrillator should not be used on a person who has chosen "No CPR." Oral fluids and nutrition must always be offered if medically feasible.
When comfort cannot be achieved in the current setting, which would include someone with "palliative and supportive care" only, the qualified minor should be transferred to a setting able to provide comfort care (e.g., compound skeletal fracture).
A qualified minor for whom their representative has chosen "palliative and supportive care" may choose or decline transport or referral to a facility with a higher level of care.
An IV medication to enhance comfort may be appropriate for a minor for whom a representative has chosen "palliative and supportive care."
Treatment of dehydration is a measure which may prolong life. A person who desires IV fluids should indicate the level of "artificially provided fluids and hydration" to be provided on the PPEL Order Form.
A qualified minor or the representative who completed the form and gave consent for the PPEL Order may revoke consent to any part of this PPEL Order at any time verbally or in writing.
IV. Review of Form.
This form should be reviewed periodically (at least annually) and a new form should be completed if necessary when: 1) the minor is transferred from one health care facility to another health care facility, or 2) there is a substantial change in the minor's health status, or 3) the treatment preferences for the minor change. It is the sole responsibility of the representative, and not the health care provider or health care facility, to periodically review this form.
V. Revoking the PPEL Order.
Whenever the form becomes invalid by verbal revocation or is replaced by an updated version, the representative of the qualified minor should draw a diagonal line through the first page, writing "VOID" in large letters across the form and signing and dating the form, or tear the form into two or more pieces.
Author: Dennis Blair
Statutory Authority: Act No. 2018-466.
History: New Rule: Filed April 18, 2019; effective June 2, 2019.