Transcript Conversations Before the Crisis: Advance Care Planning and The

Conversations Before the Crisis:
Advance Care Planning
and
The POST Project
of the
Palliative Care Partnership of the
Roanoke Valley
“Death is an inevitable aspect
of the human condition. Dying
badly is not.”
Jennings, et al, 2003
“Things Just Ain’t the Same”
How did we get here?
What is shaping EOL Care in
America?
The Need for Improved Care at
the End of Life
• Late 1800’s
• Early to mid 1900’s
• 21st Century
Cause of Death/Demographic and Social
Trends
Early 1900s
Current
Medicine's Focus
Comfort
Cure
Cause of Death
Infectious Diseases/
Communicable Diseases
1720 per 100,000
(1900)
50
Chronic Illnesses
Home
Institutions
Caregiver
Family
Disease/Dying
Trajectory
Relatively Short
Strangers/
Health Care Providers
Prolonged
Death rate
Average Life
Expectancy
Site of Death
810 per 100, 000
(2009)
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“By 2020 about half of all deaths
are expected to occur in nursing
homes.”
Source: Sheehan, D. And Schirm, V. End of Life Care of
Older Adults. AJN, Nov. 2003, 103, 11, pp. 48-57.
Impact on Death and Dying in
America
• Americans living longer
• People over 85 yo---fastest growing sector
• Living longer with progressive and eventually
fatal illness---marked functional dependency
• Isolation from death experience--increased
risk of profound emotional grief response
Impact (cont.)
• Families live far apart
• Elderly infirmed caring for elderly spouse
• Shift to curative focus has overshadowed the
obligation to provide appropriate Tx and
compassionate care
• The allure that medical technology can defer
death indefinitely
Death and Dying in America (cont.)
• Disparity between
the way people
die/the way they
want to die
• Patient/family
perspective
Source: Hunter Groninger, MD, “Palliative Care and the Patient Navigator” , March 2009. Used with permission.
SUPPORT Study…Dying in Hospitals is
Unsatisfactory
• 53% of MDs were unaware when patients had
DNR orders
• 46% DNR orders written within 2 days of death
• 38% of patients who died spent at least 10 days
in an ICU
• More than 50% of hospitalized patients had
moderate to severe pain in the last 3 days of life
Study to Understand Prognoses & Preferences for Outcomes & Risks of
Treatment, 1995
“ People want to die at home but most don’t.
They want to die free from pain, but too many
don’t. At the same time, most people don’t
want to talk about their wishes--or about dying
at all--and they either don’t know about
options for EOL care or they don’t ask for
them. . . At best, Americans have only a fair
chance of receiving good EOL care.”
--Judith Peres
Before There is a Crisis:
Turning Your Wishes for End of Life
Care into Actionable Advance
Directives:
The POST Paradigm
Is it enough to have a written
Advance Directive?
An Index Case
Mr. Jan, a 71-year-old male with severe COPD and
mild dementia, was convalescing at a skilled-nursing
facility after a hospital stay for pneumonia. Mr. Jan
developed increasing SOB and decreasing LOC over 24
hours. The nursing facility staff called EMS who found the
patient unresponsive, with a RR of 8 and an O2 sat at 85%
on room air. Although Mr. Jan had discussed his desire to
forgo aggressive, life-sustaining measures with his family
and nursing personnel, the nursing facility staff did not
document his preferences, inform the emergency team
about them, or mention his do-not-resuscitate order.
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After EMS was unable to intubate him at the scene, they
inserted an oral airway, bagged, and transported the
patient to the emergency department (2nd hospital). Mr.
Jan remained unresponsive. He was afebrile, with a
systolic BP of 190 mm Hg, P of 105 , RR of 8, and an O2 sat
of 88% despite supplemental oxygen. He had diminished
breath sounds without wheezes, and a chest X-ray showed
large lung volumes without consolidation. Arterial blood
gases showed marked respiratory acidosis. The
emergency department physician wrote, “full code for
now, status unclear.” The staff intubated and sedated Mr.
Jan and transferred him to the intensive care unit.
Lynn, et al. Ann Intern Med 2003;138:812-818.
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What went wrong?
(Could this happen in Virginia?)
•
•
•
•
•
•
Advance directives not documented
DNR order not communicated in transfer
Fragmentation in care (2 hospitals)
Overtreatment against patient’s wishes
Unnecessary pain and suffering
System-wide failure to respect pt’s wishes
– Failure to plan ahead for contingencies
– No system for transfer of plan
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What is POST?
• A physician order
• Can be completed by a non-physician
provider but must be signed by qualified
MD or DO (Osteopath)
• Complements, but does not replace,
advance directives
• Voluntary use
• Recognized by EMS and participating
facilities as a valid DDNR
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Validation of POLST
•
•
•
•
•
•
Dunn PM, et al: A method to communicate patient preferences about medically
indicated life sustaining treatment J Am Geriatric Soc. 1996;44:785
Tolle SW, et al: A Prospective study of the efficacy of the POLST J Am Geriatric Soc.
1998;46:1097
Lee MA, et al: Physician orders for life-sustaining treatment (POLST): Outcomes in a
PACE program J Am Geriatric Soc. 2000; 48:1-6.
Hickman SE, Hammes BJ, Moss AH et al. Hope for the Future: Achieving the Original
Intent of Advance Directives. Hastings Center Report 2005; Spec No:S26-S30
Hickman SE, et al. A Comparison of Methods to Communicate Treatment
Oreferences in Nursing Facilities: Traditional Practices Vs the POLST Program. J Am
Geriatric Soc. 2010; 58: 1241-1248
Hammes BJ, Rooney BL, Gundrum JD. A Comparative, Retrospective, Observational
Study of the Prevalence, Availability, and Specificity of Advance Care Plans in a County
that Implemented Advance Care Planning Microsystem. J Am Geriatric Soc. 2010;
58:1249-1255
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Results:
• Those with a POLST form indicating Comfort Care were far less
likely to receive unwanted hospitalizations and medical
interventions than those who had only a DNR order
• Those requesting fewer medical interventions continued to
receive pain and symptom mgt. identical to those without
POLST orders.
• Those with POLST forms were more likely to have orders
about medical interventions in addition to resuscitation (98%
vs. 16%)
• Those requesting full tx on their POLST—had same level of tx
as those pts. with traditional orders for full tx.
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Bottom Line
• POLST/POST is achieving its goal of honoring
tx preferences of those with advanced illness
or frailty.
• Plus----”POLST/POST is a catalyst for
conversations before the crisis
– Alvin Moss, MD; Medical Dir. Of Center for Health Ethics and Law of WV University
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Congruency of PO(L)ST Orders
Hickman, et al. JAGS, November 2011
• Study to assess whether the treatments
provided were consistent with what was
documented on the POLST form.
• Reviewed medical records and POLST forms
for 870 living and deceased patients
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Results
• Found that POLST orders about resuscitation
were honored 98 percent of the time and
orders to limit medical interventions were
honored 91 percent of the time
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Regional POST Project: The
Roanoke Valley Experience
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Regional POLST/ACP Project in the
Roanoke Valley of Virginia
Initiative of Palliative Care Partnership of
Roanoke Valley:
http://www.pcprv.org/
One hospital, two skilled nursing facilities, and
three hospices
Clinical and administrative representation from
each organization
Worked to develop a commonly acceptable
POST form
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Advance Care Planning Facilitator
training
Respecting Choices curriculum:
http://respectingchoices.org/
Fundraising from regional funding sources for
training process.
Five training sessions with about 175 facilitators
trained from multiple disciplines
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End-User Trainings
• Inservice training for health professionals who
come into contact with POST form: EMS, ED
and other specific hospital units, hospice,
nursing care facilities.
• Conducted organizational specific inservices
before “go live”
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Use of the POST Process/Form
• Began in December 2009
• Most ACP discussions and POST forms were
done in nursing care facilities.
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Some Interim Results of Pilot Project
• End user training for over 600 clinical staff at
participating facilities/agencies
• QI data collected from medical records of nearly
100 residents/patients with POST forms:
– Most forms filled out correctly
– POST orders followed as written in almost all cases
– Problem areas id’d and addressed
• Patient/Family Satisfaction Surveys: Almost all
rate the ACP session favorably
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Moving POST into Other Areas of Virginia
• POST State Stakeholders
• Groups/organizations in 8 additional localities
are planning/conducting POST Pilot Projects
over the next 2 years
• Goal: Work with stakeholders and lawmakers
to make POST a legally sanctioned document
that provides consistency, portability as well
immunity to those signing a POST form and
those who carry out the orders on the form.
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POST Pilot Project
• POST (POLST) orders legally
recognized in several states,
including WV and NC
• Roanoke Valley conducted a POST
pilot project, completed in May 2011
• Plan to make POST a legal document
recognized throughout Virginia
• 8 other regions of the state are now
conducting pilot projects
POST is for…
Seriously ill patients*
Terminally ill patients
* chronic, progressive disease/s
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Purpose of POST
• To provide a mechanism to communicate
patients’ preferences for end-of-life
treatment across treatment settings
• To improve implementation of advance
care planning
37
Living Will* v. POST
Living Will
POST
• For every adult
• Requires decisions about
myriad of future treatments
• Clear statement of
preferences
• Needs to be retrieved
• Requires interpretation
• For the seriously ill
• Decisions among presented
options
• Checking of preferred boxes
• Stays with the patient
• A physician’s order
*Fagerlin & Schneider. Enough: The Failure of the Living Will.
Hastings Center Report 2004;34:30-42.
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Why POST Works…
• MUST accompany patient
• Contains specifics
• Physician’s order—no interpretation
is needed
–Participating facilities/agencies have
agreed to accept POST order sheet
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Prompt for POST Completion
Would you be surprised
if this patient died
in the next year?
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POST: Who Should Have One?
• Anyone choosing “Do Not Resuscitate”
• Anyone choosing to limit medical
interventions
• Anyone eligible/residing in a LTC facility
• Anyone who might die within the next year
POST Form
Section A: Resuscitation
• Only section applicable to EMS
• DNR orders only apply if a person is pulseless and apneic
• POST recognized as a valid Virginia DDNR
– OEMS approval (Michael Berg)
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Section B
• Review care plan to be sure that palliative care measures available
• Institute palliative care measures as needed
• If meets admission criteria consider hospice
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Section B: Level of Medical Interventions
• Limited Additional
Measures
– Includes comfort care
described in previous
section. However, may
also use medical
treatment, IV fluids, and
cardiac monitoring as
indicated.
– Do not use intubation,
advanced airway
interventions, or
mechanical ventilation.
– Transfer to hospital, if
indicated. Avoid intensive
care.
• Full Treatment
– Includes care described in
2 previous sections.
– Use intubation, advanced
airway interventions,
mechanical ventilation,
and cardiac defibrillation,
as indicated.
– Transfer to hospital, if
indicated. Include
intensive care, if indicated.
Section B: Level of Medical Interventions
• Comfort Measures
– Treat with dignity and
respect. Keep clean, warm,
and dry.
– Use medication by any route,
positioning, wound care and
other measures to relieve
pain.
– Do not transfer to the
hospital for life-sustaining
treatment. Transfer only if
comfort needs cannot be met
in current location.
Section C: Antibiotics
Example of “Other Instructions”: Antibiotics may be
used only as needed for comfort.
(E.g., patients susceptible to UTI’s may reserve right to
be treated with antibiotic for pain and discomfort.)
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Section D: Artificial Nutrition/Hydration
• These orders pertain to a person who cannot take fluids and food by
mouth.
• IV Fluids or Feeding Tube for Defined Trial Period:
– Gives option of trying either of these to determine benefit to patient
and/or for recovery from stroke or hydration from vomiting, etc.
– Recommended trial for IV fluids = 2 to 7 days
– Recommended trial for Feeding Tube = 30 days or less
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Section E: Participants & Physician Signature
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Section F: POST Reviews & Instructions
• Related EOL documents,
if any, e.g., Living Will
• Signature of Patient or
Legal Representative
• Signature of ACP
Facilitator
• Directions for Health
Care Professionals
POST Form Shall Always Accompany
Patient/Resident When Transferred or
Discharged!*
On the top of the transfer packet!
* Note: Preferable to transfer with original current copy,
but legible copies are to be honored as though they are
the original.
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Some Interim Results of Roanoke Pilot
Project
• End user training for over 600 clinical staff at
participating facilities/agencies
• QI data collected from medical records of nearly
100 residents/patients with POST forms:
– Most forms filled out correctly
– POST orders followed as written in almost all cases
– Problem areas id’d and addressed
• Patient/Family Satisfaction Surveys: Almost all
rate the ACP session favorably
54
Moving POST into Other Areas of Virginia
• POST State Stakeholders
• Groups/organizations in 8 additional localities
are planning/conducting POST Pilot Projects
over the next 2 years
• Goal: Work with stakeholders and lawmakers
to make POST a legally sanctioned document
that provides consistency, portability as well
immunity to those signing a POST form and
those who carry out the orders on the form.
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Early Success Story
Some of the Successes
• So far, value of form recognized by clinicians
– Many PCP’s at nursing home requesting that
ACPF’s have POST ACP sessions
• Value of the RC Advance Care Planning
Process (with or without POST form)
• ACP Process/POST form has already been
reported to have been successful in guiding
appropriate end of life care based on patient’s
wishes
Some of the Challenges
• Form development
– Compliance with state DDNR and Advance Directives
– Changes in DDNR laws
– Variance in legal advice from one institution to the
other
• Portability of document: may be challenged
outside of participating organizations
– VAMC---federal regs within their system have slowed
down their being able to fully embrace the POST
project by being a participating organization
• Making sure form returns with the patient
Moving POST into Other Areas of
Virginia
• POST State Stakeholders
• A number of groups/organizations in several
localities are planning POST Pilot Projects over
the next 2 years
• Goal: Work with stakeholders and lawmakers
to make POST a legally sanctioned document
that provides consistency, portability as well
immunity to those sign a POST form and those
who carry out the orders on the form.,
Take-Home Messages about POST
• POST provides a better means than AD to
identify and respect patients’ wishes
• POST completion will improve end-of-life care
throughout the system
• Use of POST will require communication to
make it work in your community
• Consider joining the POST
Virginia Stakeholders Task Force
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RAP on POST!
Want to be trained in Advance Care
Planning Facilitation for the Seriously
Ill?
• PCPRV POST Respecting Choices Training
• Friday, December 10
• For any health care professional who wants to
learn Advance Care Planning Facilitation Skills
using the Respecting Choices Model
• Contact Laura Pole to register—
[email protected]
Address the Fear
“I’ve Seen It and I’m
Not Afraid.”
“Because your made it normal,
we could make it holy.”
Rachel Naomi Remen, from My Grandfather’s Blessings
Contact Information
Laura Pole, RN, MSN, OCNS
POST Pilot Project Coordinator
[email protected]
Palliative Care Partnership of the Roanoke Valley
www.pcprv.org