Transcript Presentation - South Carolina Medical Association

Communication
Review of Systems
An Aid for Caring for the Seriously Ill
South Carolina Healthcare Ethics Network Annua
Meeting
Summit on Care of the Seriously Ill
Mark A. O’Rourke, M.D.
October 12, 2011
Communication Review of
Systems (C-ROS)
1.
2.
3.
4.
5.
6.
7.
Ability to Consent
Patient Voice
Physician Voice
Patient Understanding
Physician Understanding
Advance Directives
Decisions
Case for Improved Communication,
Consent and Decision-making
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Experience with hospital ethics committees in South Carolina, communication
problems are frequently the beginning of disputes with patients and families.
End-of-Life Transitions among Nursing Home Residents With Cognitive Issues,
Gozalo P et al, N Engl J Med 2011;365:1212-21, September 28, 2011.
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Burdensome transitions are common, vary according to state, and are associated with
markers of poor quality in end-of-life care.
Ultimately, a decline in burdensome transitions will come about through a combination
of:
 Improved provider incentives, and
 Decision making that elicits and respects the needs of the choices of the patients.
Reducing Unnecessary Hospitalizations of Nursing Home Residents, Ouslander
JG et al, N Engl J Med 2011;365:1165-67, September 28, 2011.
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Change financial incentives to hospitalize a patient from a nursing home.
Improve acute care in nursing homes, including communication strategies.
Variation in Rates of Burdensome Transitions among 474,829 Patients, According to State.
Gozalo P et al. N Engl J Med 2011;365:1212-1221
State Variations in the Proportion of Nursing Home Residents with Advanced Cognitive
Impairment Who Had at Least One Burdensome Transition.
Gozalo P et al. N Engl J Med 2011;365:1212-1221
le and Potentially Avoidable Hospitalizations of Nursing Home Residents Eligible for Both Medicare and Medi
Ouslander JG, Berenson RA. N Engl J Med 2011;365:11651167.
Case for Improved Communication,
Consent and Decision-making, p.2
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Patient and Family Surveys, including the SUPPORT study.
Physicians speak out:
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Levinson W et al. Physician Communication, It’s About Time. JAMA 2011;305:1802-03.
Astrow AB et al. The Palliative Care Information Act in Real Life. N Engl J Med 2011;1885-87.
Billings AJ et al. On Patient Autonomy and Physician Responsibility in End-of-Life Care.
Archives Intern Med 201;171:849-53.
Zeytinoglu M. Talking It Out: Helping Our Patients Live Better While Dying. Ann Intern Med
2011;154:830-32.
Proposed solutions:
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Physicians should take more time to communicate better.
Medical schools should improve how they teach communication.
Medicare, Medicaid, and health insurance companies should reimburse physicians better for the
time and effort spent in communication.
Academic medical centers could apply the science of quality improvement to analyze
“communication errors” and develop quality improvement plans.
Controlling Death: The False Promise of
Advance Directives. Henry S. Perkins, MD
Annals Intern Med 2007;47(1):51-57
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“Advance directives simply promise more control
over future care than is possible. Unexpected
problems arise repeatedly to defeat advance
directives.”
“I conclude that, while drawing lessons from
advance directives, advance care planning must
evolve beyond them.”
“Advance care planning must refocus from
completing advance directives to preparing
patients and families for the uncertainties and
difficult decisions of future medical crises.”
Communication Review of
Systems (C-ROS)
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A clinical tool
Part of the History and Physical Exam with
Present Illness, Past History, Family
History, Social History, (physical) Review
of Systems
Completed by the physician, like the H&P,
when a patient is admitted to the hospital
The admitting physician may get help from
the multidisciplinary team.
Communication Review of
Systems (C-ROS)
1.
2.
3.
4.
5.
6.
7.
Ability to Consent
Patient Voice
Physician Voice
Patient Understanding
Physician Understanding
Advance Directives
Decisions
Ability to Consent
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Determine the patient’s mental capacity to consent to
care and to procedures in the hospital. A patient
interview is a helpful first step. Care partners, prior
documentation or documentation of legal
incompetence may help as well.
If the patient is not able to consent to care and
procedures, determine the appropriate person who is.
Patient Voice
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If the patient is able to consent, determine who the
patient has, or wants to have, to help with consent,
communication, and decision-making. The patient
voice may be the patient alone, but may include a care
partner. The care partners may be a spouse, fiancé,
partner, parent, child, sibling, friend, associate,
caregiver, or a significant other person.
The patient may already have designated a
spokesperson in writing.
When many care partners are involved, agreement on
one to be the point person for ongoing communication
with physicians may help.
Physician Voice
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Determine who are the various physicians or
physician groups involved in the patient’s care. In
addition to the admitting physician, there may be
multiple consultants, including hospitalists.
Identify for the patient and care partners which
physician will play the lead role in managing the
patient’s care while in the hospital.
Determine which physicians outside of the
hospital are involved in the patient’s care for
purposes of communication and coordination of
subsequent care.
Patient Understanding
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Determine the patient’s and care partners’
understanding of the patient’s situation in the
hospital. Open-ended questions help patients and
care partners express their understandings, beliefs,
values, and emotions.
Topics to ask about include the reason for
admission, events during the hospital stay, and the
patient’s health prior to admission.
Additional topics to ask about include expected
outcome and prognosis for this hospital stay and in
the future.
Physician Understanding
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Determine, articulate, and explain the physicians’
understanding of the patient’s situation in the
hospital, to include the reason for admission,
events during the hospital stay, and the patient’s
health prior to admission. Additional topics to
address include expected outcome and prognosis
for this hospital stay and in the future.
Advance Directives
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Determine whether patient has any advance
directive documents. Ask whether the patient
would like information about advance directives
or to complete advance directive documents.
In 2010, South Carolina law provides for several
documents:
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Living Will (Declaration of Desire for Natural Death)
Health Care Power of Attorney
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Five Wishes
Decisions
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Determine what decisions may need to be
made immediately or later during this
hospital stay.
Arrange the schedule and manner of
communication between the physicians and
the patient and care partners during this
hospital stay.
Why will the C-ROS help with
Communication, Consent and
Decision-Making in hospitals in SC?
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The Communication Review of Systems is a uniform
process.
A uniform process can change the medical culture for:
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Physicians and others in a hospital system
Hospitals across the state
Physicians and others over the continuum of training
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Medical school
Postgraduate training
In practice
Patients at various times, with various physicians, at various
hospitals, under various circumstances.
Communication Review of
Systems (C-ROS)
1.
2.
3.
4.
5.
6.
7.
Ability to Consent
Patient Voice
Physician Voice
Patient Understanding
Physician Understanding
Advance Directives
Decisions
C-ROS Example: 65 y/o female admitted
with weakness, weight loss, and Hb 6.0.
1. Consent: Mrs. Carlson has had capacity to consent, but
she is lethargic and having difficulty processing
information.
2. Patient Voice: Patient lives alone, with her oldest daughter
nearby. She is relying mainly on her daughter for support
at this time.
3. Physician Voice: Dr. James is the hospitalist and admitting
physician. He will be the lead physician, and the
consultants will report to him. Because of suspected
blood loss in the intestines, a gastroenterologist will be
consulted. If it appears that surgery might be necessary,
a surgeon will be consulted. Dr. James or one of his
partners will see the patient each morning on rounds,
around 7:00 am.
C-ROS Example: 65 y/o female admitted
with weakness, weight loss, and Hb 6.0, p.2
4. Patient Understanding: Mrs. Carlson does not go to
doctors regularly. She thinks that her condition is caused
by stress in her job at a convenience store.
5. Physician Understanding: Dr. James is concerned that the
patient might have a bleeding ulcer or maybe a cancer of
the intestines.
6. Advance Directives: Patient does not have a living will or a
HCPOA. If she cannot speak for herself, she would like
for her daughter to make decisions for her.
7. Decisions: Mrs. Carlson may want to learn about and
consider a health care power of attorney and/or a living
will.
C-ROS Example: 45 y/o male with history of HIV,
remote history of lymphoma, and recent history of
pneumonia, admitted with pain, inanition, altered
mental status, lung nodules and a liver mass
1. Consent: Mr. Dean is delirious. His male partner came
with him to the hospital. There is apparently no HCPOA
or guardianship.
2. Patient Voice: He is divorced. He relies on his domestic
partner of 16 years. His father and mother live locally, but
are estranged and are uncomfortable with the partner.
3. Physician Voice: Dr. Jenkins is the admitting hospitalist.
The ID doctors know the patient and consider him a
noncompliant sociopath. The patient does not have a
primary care physician or a medical oncologist. Dr.
Jenkins is the lead physician.
4. Patient Understanding: He was treated for lymphoma in
another city five years ago, but does not recall the name
of the facility or the doctor. He does not know why he is
in the hospital.
C-ROS Example: 45 y/o male with history of HIV,
remote history of lymphoma, and recent history of
pneumonia, admitted with pain, inanition, altered
mental status, lung nodules and a liver mass, p.2
5. Physician Understanding: Dr. Jenkins knows that the patient is
weak with undertreated HIV and the masses in the lung and
liver. If the patient has a malignancy, it is not at all clear how
successful any treatment might be.
6. Advance Directives: No known living will or HCPOA.
7. Decisions: Make an immediate effort to involve the parents
who are the next of kin. . Meet with parents and domestic
partner to determine lead decision-maker. Note that the
person with higher priority as surrogate under the SC
HealthCare Decisions Act may delegate authority for
decision-making. There is a definite problem with consent
and decision-making. Consult the palliative care service (or
ethics committee consultation if palliative care consultation is
not available). Get oncology consultation to determine if
there is a malignancy and, if so, the prognosis.
Communication Review of
Systems (C-ROS)
1.
2.
3.
4.
5.
6.
7.
Ability to Consent
Patient Voice
Physician Voice
Patient Understanding
Physician Understanding
Advance Directives
Decisions
Focus on Seriously Ill
Inpatients
Focus on Seriously Ill Inpatients
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Kelly AS, Morrison RS et al. Determinants of Treatment
Intensity for Patients with Serious Illness: A New Conceptual
Framework. J Pall Med 2010;13(7), online August 4, 2010,
DOI: 10.1089/jpm.2010.0007
The inability to accurately predict life expectancy for individual
patients with serious illness, the innate human struggle to
avoid death, and modern political realities pose challenges to
policies designed to improve end-of-life care. Instead, reform
efforts should focus more broadly on all patients with serious
and life-limiting illness. Therefore, we propose a new
conceptual framework to guide research and policy aimed at
enhancing healthcare efficiency and promoting goal-directed
care of patients with serious illness.
Focus on Seriously Ill
Inpatients
Focus on Preparing Patients for
Decision Making
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Sudore RL, Fried TR. Redefining the “Planning” in Advance
Care Planning: Preparing for End-of-Life Decision Making.
Ann Intern Med 2010; 153:256-261 (17 August 2010)
“Given the problems with prespecified treatment preferences,
we propose that the main objective of advance care planning
be to prepare patients and surrogates to participate with
clinicians in making the best possible in-the-moment decisions.”
“This approach does not preclude the completion of an advance
directive but recognizes that it is just one piece of information to
be used during in-the-moment decision making.”
C-ROS Summary
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The C-ROS is a communication checklist. It needs to be
studied and tested like any other checklist or quality
improvement process.
The C-ROS is simple, inexpensive, and intuitive.
How to administer the C-ROS:
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Start with “For medical issues, who would you
want to speak for you if you could not speak for
yourself?”
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Ask “Do you have a Healthcare Power of
Attorney?” Then explain what it is, etc.
South Carolina Coalition for
Care of the Seriously Ill
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The SC Coalition for the Care of the Seriously Ill (SC Coalition CSI)
is comprised of clinical and administrative leaders representing key
statewide organizational partners, healthcare entities, and
individuals that have agreed to collaborate in a major statewide
initiative to redesign care, improve quality of life, and protect the
ethical rights of the seriously, chronically, or terminally ill in S.C.
Members of the Coalition for 2010 include:
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South Carolina Medical Association
The Carolinas Center for Hospice and End of Life Care
the South Carolina Hospital Association
the SC Healthcare Ethics Network
The S.C. Society of Chaplains
LifePoint
AARP
South Carolina Nurses Association
South Carolina Coalition for
Care of the Seriously Ill - Charter
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Vision Statement: SC delivers excellent communication and
shared decision-making for persons with serious, chronic, or
terminal illnesses.
Mission Statement: All persons in SC with serious, chronic,
or terminal illnesses will have an active voice in the care
decision process.
The Coalition will set the vision, mission,and strategic aims
and will provide guidance and monitor the impact and value of
its work.
It will also seek grant funding to accomplish the strategic aims
and promote alignment of public policy with the Coalition’s
mission.
SC Coalition for the Care of the
Seriously Ill --- Project List
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Template hospital policy, entitled Communication, Consent, and DecisionMaking Process for Seriously Ill Inpatients, and the template progress note,
entitled Allow Natural Death or Limited Resuscitation. This is in the process of
adoption and implementation at MUSC with the active involvement of Dr. Walter
Limehouse.
Communication Review of Systems (C-ROS). It is a clinical tool that
complements the template policy and progress note. It is in the process of pilot
testing at Greenville Hospital System under the leadership of Dr. Mark O’Rourke.
Palliative care bundle (Nelson JE, et al. Improving Comfort and
Communication in the ICU: a practical tool for palliative care performance
measurement and feedback. Qual Safe Health Care 2006;15:264-271), currently
being introduced at Roper-St. Francis in Charleston under the leadership of Dr.
Scott Lake. It is a tool that records data on ten parameters found in the medical
record to assess the quality of palliative care in an ICU over time.
SC Coalition for the Care of the
Seriously Ill --- Project List
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Document to be called the South Carolina Palliative Care
Resource Toolkit.
Adoption of uniform language in hospitals across the state for the
documentation of the status of an inpatient with regard to
cardiopulmonary resuscitation.
Development statewide of advance directives in the form of
physician orders for life sustaining treatment (POLST) that can
accompany a person from an outpatient setting, such as a nursing
home, to an inpatient setting.
What Is Palliative Care?
Medical treatment that aims to
relieve suffering and improve quality
of life simultaneously with all other
appropriate treatment for patients
with advanced illness, and their
families.
Domains of Palliative Care
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Communication, help with medical
decision-making
Expert symptom assessment and
treatment
Psychosocial and practical support,
care coordination, and bereavement
services
Stages in the Continuum of Palliative Care
Curative
Care
Active
Palliative
Symptomatic Supportive
Palliative
Palliative
Patient
Goal
Cure
Prolong life/ Comfort
Survive
Comfort
Disease
Goal
Eliminate
Arrest/
Control
Some
Control
No Control
Mind Set
Win
Fight
Acceptance
CPR
Appropriate?
Yes
Probably
Hope/Live
with it
Varies
Hospice
Appropriate?
No
No
Maybe
Yes
No
The Center to Advance
Palliative Care (CAPC)
Provides health care professionals with the
tools, training and technical assistance
necessary to start and sustain successful
palliative care programs in hospitals and
other health care settings.
CAPC is a national organization dedicated to
increasing the availability of quality palliative
care services for people facing serious
illness. www.capc.org
Director: Diane E. Meier, MD, FACP