Transcript Physician Orders to Ensure Advance Directives

Getting What You Want in
End of Life Care
Kenneth Brummel-Smith, M.D.
Charlotte Edwards Maguire Professor and Chair,
Department of Geriatrics
Florida State University College of Medicine
Objectives
• Describe the problem of dying in
America
• Describe common myths about end of
life care
• Describe steps you can take to control
your life – and dying process
Remaining Life Expectancy
Women
Men
Walter LC, JAMA, 2001
Causes of Death (>65)
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Heart disease
Cancer
Stroke
Pneumonia
Diabetes
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Falls
Atherosclerosis
Kidney failure
COPD
Cirrhosis
Aging is personally modifiable!
Truisms
• Everybody’s going to die
• Most people don’t want to deal with it
• Doctors will always do something,
especially when they aren’t sure what to
do
• The only way to get what you want is to
plan for it
Common End of Life Medicine
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Hospitalization
No hospice referral
Lots of medications
Artificial nutrition (“Tube feeding”)
Intravenous tubes
CPR – cardiopulmonary resuscitation
Disease Trajectory
Full
Function
Death
50
80
Artificial Nutrition Myths
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Prolong life
Reduce suffering
Decrease aspiration
Ordinary care
Prolong Life?
• 50%-68% 1 year mortality (Cowen, Callahan)
• dementia
• stroke
• CHF
• Survival same as hand fed (Mitchell)
• Improvement in nutritional measures
does NOT affect survival! (Golden, Kaw,
Mitchel)
Reduce Suffering?
• Complication rate 32% - 70% (Taylor)
• Those without hunger or thirst have
increased pain with ANH (McCann)
• Increased use of restraints
• Up to 90% (Peck)
• NOT significantly different with G tubes
(Ciocon)
• 70% had no improvement in function or
subjective health status (Callahan)
Decrease Aspiration?
• NG tube • 67% aspirated
• 43% developed pneumonia
• 66% pulled out
• G tube
• 44% aspirated
• 56% developed pneumonia
• 56% pulled out
(Ciocon)
Ordinary Care?
• Decreased human contact (Slovenka)
• Supreme Court ruling in Nancy
Cruzan
• Religious stands
• Catholic - burdens and benefits
• Jewish - impediments to dying
Loaded Words
• Starvation
• Dying of thirst
• Wasting away
Benefits of Dehydration
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Lack of thirst
Decreased phlegm production
Decreased urine production
Euphoria
Analgesia
Anaesthetic effect
CPR – How Successful?
• Television - ?
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Majority – trauma
65% children and young adults
75% success rate
Rescue 911 - 56% used the term “miracle”
• Real life - ?
New England Journal of Medicine 334 (24): 1578–1582
CPR in Hospitals
• 14% overall survival in hospitals
• 3% on general medical wards
• 80% of those with restored heart rate
are comatose
• 50% of survivors do not want CPR
again
• 50% of survivors develop major
depression or functional decline
“survival” – leave the hospital
CPR in NH
• 0%-3% survival rates in NH
• 4% of facilities have “No CPR”
policies
• 23% never initiate - call EMT
Definitions
• Advance Directives
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Living Will
Durable Power of Attorney for Health Care
Surrogate decision maker
Mixed Advanced Directives
• 5 Wishes
• Advance Care Plan Document – Project Grace
• Do Not Resuscitate Order-DNRO (“Yellow Form”)
• POLST - an “actionable advance directive”
Benefits Of Advance Directives
• Discussions between family members
• Clarifying preferences
• Educating about risks and benefits of
different treatments
• Dispelling myths
• Ensuring desired or preventing
undesired treatments?
Limitations of Advance Directives
• Usually not available in clinical settings
• Do not provide clear guidance to
emergency personnel
• Only 17% - 25% of people have them
• Variations in forms
• Terms may be unclear to clinicians
• Don’t work – SUPPORT study
Angela Fagerlin and Carl E. Schneider, “Enough: The Failure of the
Living Will,” Hastings Center Report 34, no. 2 (2004): 30-42.
Will Better Discussions Work?
• SUPPORT Study:
• System-level innovation … may offer
more powerful opportunities for
improvement.
• Physician behavior is not altered
significantly by addressing poor
communication alone.
• The fundamental problem may be
structural and institutional.
Lynn, J. Ineffectiveness of SUPPORT, JAGS, 48: 2000
Murray TH, Improving EOL-Why So Difficult? Hastings Ctr Report, 2005
Why Advance Directives Are Not
Followed
• Drs (or family) don’t see the patient as
hopelessly ill
• Contents of the directive are vague
• Family member is not available or
unable to make the decision
• Family members disagree with the
person’s choice
Teno, J Gen Intern Med, 1998;13:439
Florida Case #1
• Madeline Neuman – 89 y/o Fl nursing
home resident completed an AD
• Found unresponsive – resuscitated,
intubated - 3 granddaughters persuaded
Drs to cease treatment – she died after
1 week in Intensive Care Unit
• GDs successfully sued Joseph Morse
Geriatric Center in West Palm Beach
Florida Case #2
• Hanford Pinnette – 73 y/o man in ORMC in Orlando
with end-stage heart failure, kidney failure and on a
ventilator
• Had executed an AD and named his wife as
surrogate
• Drs recommended ending life-sustaining Tx in
accordance with his living will
• Wife refused and said she could communicate with
him
• Hospital went to court and won – LST was stopped
and he died
FL Living Will - Myths
• Only way to limit interventions
• Have to fit one of the 3 categories
• End stage disease, terminal condition,
persistent vegetative state
• Must have 2 physicians “decide”
• Have to be incapacitated
Better Option
• Physician Orders for Life-Sustaining
Treatment
•“POLST” form
Purpose of POLST
• To ensure that patient preferences are
followed
• To provide a mechanism to
communicate patient preferences for
end of life treatment across treatment
settings
• Home
Hospital
Nursing home
National Use of POLST
What is POLST?
• A physician order
• Can be completed by any provider but
must be signed by MD
• Complements, but does not replace,
other advance directives
• Voluntary use, but provides a
consistent, easily recognized document
Basis of POLST
• Discussion regarding advance care
preferences
• With patient
• With surrogate decision maker (or proxy)
if patient does not have capacity to make
decision
• The POLST can be changed by the
surrogate, based on proper ethical principles
1
Percentage of Participants Who Received Less, Same, or More Care than Requested .
Amount of Care Received
Less Than Requested
Percent
Same as Requested
More Than Requested
100%
94%
91%
90%
86%
84%
80%
70%
60%
50%
46%
40%
33%
30%
20%
20%
14%
10%
4%
13%
6%
3%
3%
3%
0%
CPR (N=54)
1
Medical Intervention
(N=54)
Antibiotics (N=28)
IV Fluids (N=38)
Feeding Tubes (N=34)
Areas of Care and Valid Reponses
Percentages exclude participants for whom care was not applicab le.
Lee, Brummel-Smith, Meyer, Drew, London. J Am Geriatr Soc, 2000; 48:1219
Newest Study
• Compared NH residents with POLST to
those without one
• 1711 residents
• Three states – Oregon, West Virginia,
Wisconsin
Hickman SE, et al. J Amer Geriatrics Soc, 2010
Results – Orders in Chart
%
100
90
80
70
60
50
40
30
20
10
0
POLST
No POLST
Hosp
AB
ANH
CPR
Section A: Resuscitation
• Resuscitate
• Do Not Resuscitate (DNR)
• Order only apply if a person is pulseless
and not breathing
• Some have suggested changing this term
to “AND” – Allow Natural Death
Section B – Three Levels
• Comfort Measures Only
• Transfer to hospital only if comfort needs cannot
be met
• Limited Additional Interventions
• Do not use intubation or artificial ventilation, avoid
ICU
• Full Treatment
• Use intubation & ventilation, cardioversion,
pacemaker insertion, ICU
Sections C and D
• Antibiotics
• No antibiotics
• Evaluate whether limits exist
• Use antibiotics
• IV and Artificial Nutrition
• No nutrition by tube or IV fluids
• Use for a defined trial period
• Use long term
Section E
• Basis for Orders
• Who was it discussed with?
• A summary of the medical condition(s)
• Signatures
Comfort Measures Always Provided!
• Each level of care starts with comfort
• Each successive level includes the
previous level
• Even those receiving “full treatment”
need comfort
• SUPPORT study – majority of dying
patients had untreated, but controllable
symptoms
Where to Keep the POLST
• The front of the chart if admitted
• In a red envelop on the fridge (makes it hard
to read when in envelope)
• Goes with resident (patient) on transfer to
another facility
• Comes back with resident
• Photocopies stay in medical chart (or EHR)
after discharge or in physician’s office
FL POLST Initiative
• Center for Innovative Collaboration of
Medicine & Law
• Marshall Kapp, J.D., MPH – Director
• http://med.fsu.edu/medicinelaw/
• Alyson Odom
Program Associate
850-645-9473
• Donations appreciated!
References
• My Mother, Your Mother: Embracing
"Slow Medicine," the Compassionate
Approach to Caring for Your Aging
Loved Ones
• Dennis McCullough
• Sick to Death and Not Going to Take
It Anymore
• Joanne Lynn