Transcript Advance Directive POLST

Building a Community Partnership
Focused on Advanced Care Planning
Lancaster General Health
Landis Homes
The Evolution of Advance
Directives: from Living Wills to
POLST
Maggie Costella, Lancaster
General Hospital
Objectives
• Understand the purpose of advance
directives
• Recognize the importance of advance
directives
• Understand the difference between
an advance directive and a POLST
HOW AMERICANS DIE
20% of Americans die in intensive care units,
part of the 50-60% who die in hospitals
4
Mrs. R . . .
• … an 86 year old retired homemaker and widow
• Lives in an apartment in a senior living
community
• Increasing abdominal pain, nausea, and fever
• Medical conditions include heart disease
(controlled with medications), diabetes
(controlled with insulin), and mild forgetfulness
• To the emergency department then admitted
with diverticulosis and urinary tract infection
. . . Mrs. R
• Physician says Mrs. R should feel better soon, but
asks about resuscitation “if something
unexpected happened, her heart stopped, and
she died.”
• Mrs. R says, “I just want to go back to my
apartment. I don’t want to be on any life support
machines and I don’t want to think about things
like that. My daughter will take care of things if
something like that happens.”
. . . Mrs. R
• How does her family know what to decide?
• Do they have the authority to decide?
• What documents are most helpful?
Patient Decision Making
• Every adult person of sound mind has a
constitutional right to make decisions
regarding his or her care.
• A competent patient has the right to refuse
treatment or make a bad decision even if it
means he/she will die.
Advance Care Planning
• Advance Directives help care givers know
what type of care an individual wants when
they cannot speak for themselves.
• Advance Directives allow people to retain
control over the care they receive.
Advance Care Planning
• Principles of biomedical ethics:
– Autonomy
– Beneficence
– Non-maleficence
– Justice
What is an Advance Directive?
• A document prepared in advance of the need
for health care that expresses an individual’s
wishes for future health care
• Two types:
– Living Will
– Health Care Power of Attorney
Living Will
• A document that expresses wishes for health
care when faced with end-of-life decisions
• Enables someone to express wishes about:
– Artificial nutrition and hydration
– Cardiopulmonary resuscitation
– Artificial respiration
– Other health care services
Living Will - When Does It Apply?
• Living Wills usually pertain to end of life care
• Family members and physicians must follow
the instructions in a Living Will when:
– The individual is unable to make decisions; and
– The individual is either permanently unconscious
or suffers from an end-stage medical condition
Health Care Power of Attorney
• A document that appoints someone to make
health care decisions for the individual executing
the document.
– Not limited to end-of-life decisions.
– The person appointed is the “Health Care Agent.”
• Health care agents make decisions for the
individual when the individual is unable to make
his own decisions.
Decisions a Health Care Agent can Make
• Typically, can make decisions regarding:
– Surgery
– Continuation or withdrawal of life-sustaining
treatment
– Admission to a nursing home
– Donation of organs
Health Care Power of Attorney
• As long as an individual is competent, then the
individual controls the care she receives.
What Happens When There is no Advance
Directive?
• When an individual is unable to make decisions
for themselves and there is no advance directive,
the law appoints someone to make decisions.
• This person is called a “Health Care
Representative.”
• Typically, the Health Care Representative is a
close family member.
Health Care Representative
• The law lists who can serve as the
health care representative:
– Spouse and adult children from a prior
relationship
– Adult children
– Parents
– Siblings
– Grandchildren
– Any adult who knows your values/beliefs
(close friend, niece/nephew, etc.)
What Decisions Can a HC Representative
Make?
• Typically, can make most medical decisions,
such as:
– Consenting to surgery or other medical treatment.
– Authorizing admission to a nursing home.
What Decisions Can a HC Representative
Make?
• However, representative cannot withhold or
withdraw life-sustaining treatment unless
individual is permanently unconscious or
suffers from an end-stage medical condition.
Multiple Representatives
• It is possible to have more than one
representative.
– For example, if the patient’s spouse is deceased
and the patient has three adult children, the three
children will make decisions for you.
Multiple Representatives
• If the health care representatives disagree
about what care to provide, the doctor and
hospital will follow the majority decision.
– For example, if two children want to withdraw lifesustaining treatment, but the third child wants to
continue it, the health care provider will withdraw
treatment.
Relying on a Health Care Representative
• John is 55 years old and married with two
adult kids.
• John divorced his first wife 25 years ago
and has two other children from his first
marriage.
• John does not have an Advance Directive.
• John has a heart attack.
Cont’d
• John is unresponsive and the medical
team is concerned about severe brain
injury from lack of blood and oxygen.
• Medical team thinks it is unlikely John will
regain consciousness.
• John’s current wife and kids want to
withdraw care.
• John’s ex-wife and his kids from his first
marriage want to continue treatment.
Relying on a Health Care Representative
• Even though the law appoints a close family
member as a representative, it’s still
important to have an Advance Directive
because:
– Family might not know what your treatment
wishes are.
– Family might disagree on what care is
appropriate.
– Family members who the patient does not
want making decisions for them, might be the
ones making decisions.
Advance Directives: Limitations
• Advance directive may not be available.
– Not completed by most adults.
• only about 20% of Pennsylvanians have completed
– Not transferred between health care settings.
• Advance directive may not be specific.
– About current diseases or conditions.
– Regarding preferences about non-procedural
issues.
Advance Directives: Limitations
• Advance directive may not have resulted in discussion.
– Individual just completed form.
– Surrogate/family and medical team left to interpret.
• Advance directive may not be current; resulting in greater
uncertainty about treatment preferences.
• Advance directive may not be followed if terminal status
unclear.
• Advance directive does not immediately translate into
physician order.
“POLST”
A method to define patients’ preferences for end-of-life
treatment and communicate them across care settings.
Turn treatment preferences and advance directives into
medical orders.
POLST
• Pennsylvania Orders for Life Sustaining
Treatment.
• Type of advance care planning tool.
• Intended for individuals who are ill and have a life
expectancy of 1 year.
• Does not replace a Living Will or Health Care
Power of Attorney.
POLST
• Current medical orders, not preferences late.
• Allows individuals to express type of care desired.
– CPR
– Artificial Nutrition/Hydration
– Full or limited interventions
• Transfers with the individual.
– Ideal for individuals in nursing homes or rehabilitation
centers
POLST
• Approved, standardized form, bright distinct
color.
– “Pulsar pink”
• Complements advance directives.
• The POLST form is kept in a prominent/known
place.
– Home: refrigerator, bedside table, wall above bed
– Health care facility: front of the medical chart
POLST is for…
• Seriously ill persons.
– chronic, progressive disease
• Persons with end-stage medical condition.
• Terminally ill persons.
• Persons with advanced frailty.
Use of the POLST form is usually not appropriate for
persons with stable medical or functionality problems
or who have many years of life expectancy.
POLST Form Requirements
• Patient name.
• Resuscitation orders.
• Physician/NP/PA signature.
• Patient (or legal medical decision-maker)
signature.
All other information is optional
POLST
• Provides medical orders and specific information.
– Resuscitation: CPR or Allow Natural Death
– Other medical interventions
• 3 categories with escalating levels of interventions
• May be used to limit medical interventions OR
clarify a request for all medically indicated
treatments including resuscitation.
• Based on conversation for goals of care.
Advance Directive or POLST
Advance Directive
POLST
Population
All Adults
Serious illness or frailty
Timeframe
Future care/future conditions
Current care/current
condition
Who completes form
Individuals/Patients
Health Care Professional
Where completed
Varies
Medical setting
Resulting product
Surrogate appointment and
statement of preferences
Medical orders based on
shared decision-making
Surrogate role
Cannot complete
Can consent if patient lacks
capacity*
Portability
Patient/family responsibility
Health Care Professional
responsibility
Periodic Review
Patient/family responsibility
Health Care Professional
responsibility to initiate
Advance Care Planning
Age
18
Complete an Advance
Directive
Update Advance Directive
Periodically
Diagnosed with Serious or
Chronic, Progressive Illness,
including Dementia*
Consider a
POLST Form
Treatment Wishes
Honored
Materials adapted from the
Coalition for Compassionate
Care of California
*Someone for whom you
would not be surprised if
they died within a year
ONE COMMUNITY’S
EXPERIENCE WITH POLST
NEELOFER SOHAIL, MD, CMD
Geriatric Specialists
Lancaster General Hospital
WHY IT STARTED
• ISSUES
– Nursing home orders
– EMS acceptance of advance directives
– Advance directives not present at the right time
– Patients were getting unwanted care.
HOW IT STARTED
 Getting together of champions from hospital
and SNFs- July 2010
 Send out invitations to the SNFs, CCRC’s,EMS,
ED staff, Home health agencies, Hospice, adult
day care, lawyers.
 First meeting in October of 2012 with support
of the Lancaster Medical Society- Judith Black
introduced the community to the POLST
 A task force was set up with varied members.
PROCESS
 Several groups were assigned with champions
to help the process.
 SNF, Hospital, EMS, Adult Day care and
Hospice and home health agencies.
 Policy and procedures were reviewed by all
the involved parties.
 These were implemented after fine tweaking
them for the different facilities.
PROCESS
• Meetings were set up of the different groups
and also of the task force to trouble shoot
issues.
• A few of the facilities volunteered to be pilot
facilities including the hospital.
• Transfer of residents started between hospital
and pilot SNF facilities.
• Education continued- SNFS, hospital and
community at large.
BARRIERS
 Physicians
 Standardization
 Administration
 Time to educate and implement
 Designating a person to initiate and discuss form.
 Losing the original forms.
OVERCOMING THE BARRIERS
• Education of nursing home and hospital
physicians at varied settings.
• Journal club discussion at hospice.
• Small groups of champions visiting physician
offices.
• Medical staff meeting at hospital and SNFs.
• Education and modeling by medical directors
at their facilities.
CONSISTENCY
• Standardization of the POLST form as the
standard advance directive form in all
participating facilities.
• Appointing point persons at each of the
participating locations to trouble shoot.
• Maintaining consistency in placing the form in
the patients chart.
• Have a process flow for the form.
INITIAL PROCESS
• Education of administration at facilities about
the POLST.
• Review with legal at all facilities.
• Involvement of the Bar association.
• Having combined meetings of the PMS and
the Bar association for providers.
BARRIERS
• A lot of time involvement from all involved.
• Issues with physician time and productivity in
doing the form with patient or family.
• CCRC units needed more time to involve all
sections of their communities.
WHO IS RESPONSIBLE
• Person initiating the form
• Person actually doing the form.
• Discomfort of non medical personnel at
having to do the form.
• Physicians not wanting to do the form,
difficulty initiating conversations.
OTHER ISSUES
• Losing the form was a big issue during the
transition.
• Multiple Pulsar pink copies kept in the chart.
• Communication amongst the facilities-having
point persons is very important
Educate, Educate, Educate
 Providers (physician, NP, PA) SNU and hospital
 Nursing staff-SNU, hospital (especially ER and ICU)
 Social work, administration, others
 Patients, families, community
 Importance of having respected physician champion(s),
as well as nursing champion(s) and administrative
support in facilities
AT THIS TIME
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Landis Homes
Conestoga View
Willow Valley
QV Presbyterian
Mennonite Home
Luther Acres
Masonic Homes
St. Anne’s
Ephrata Manor
United Zion
Maple Farms
Calvary Fellowship
LET US
NOT FAIL
THE
ELDERLY
OF THE
FUTURE,
FOR THEY
ARE US
51
POLST impacts on the CCRC
Charles Maines, MBA, NHA
Director of Admissions\Social Services
Landis Homes
Champions
• Medical director – Dr. Dale Hursh, MD, CMD
• Administrator of Healthcare – Ethel Caldwell, RN,
NHA
• Director of Admissions\Social Services
Supported by administration through the Vice
President of Operations
Building the process
• Meeting with the taskforce
• Developing policy and procedures
• Educate, Educate, Educate
Physician educate
• Hosted a breakfast for all primary care
physicians who attend to patients
• Sent a letter signed by the Medical Director
regarding POLST to all primary care physicians
who attend to patients
Team member educate
• Department Director\Supervisor meeting
• RN\LPN meeting
• Social Service department meeting
• House meetings
Resident\Families Educate
• Town meeting
• Hosted a education session for residents and
their families
• Sent a letter regarding POLST to all residents
and\or their responsible person
Initial implementation
• Started in the healthcare in June of 2011
• Started in the personal care home and
residential living in October 2011
Ongoing education
• All admissions receive The Pink Link to your
wishes for care
– Information for patients and family members
• Review of advanced care planning
– At least, quarterly in healthcare
– At least, yearly in personal care and residential
living
Questions:
Contact Information
• Margaret Costella, JD - Senior Vice President,
Legal Services & General Counsel at Lancaster
General Hospital
– [email protected]
• Neelofer Sohail, MD – Geriatric Specialist at
Lancaster General Hospital
– [email protected]
• Charles Maines, MBA, NHA – Director of
Admissions\Social Services at Landis Homes
– [email protected]