Transcript The role of the Primary Care provider in Advanced Care Planning

THE ROLE OF THE PHYSICIAN
IN ADVANCE CARE PLANNING
FOR PATIENTS WITH
SERIOUS ADVANCED ILLNESS
This presentation was created by the VA POST Collaborative.
Special thanks to:
Chris Pile, MD
Laura Pole, RN, OCNS
Matthew Kestenbaum, MD
Carol Wilson, MS
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This program is sponsored in part by a
grant from the Geriatric Training and
Education (GTE) funds appropriated by
the General Assembly of Virginia and
administered by the Virginia Center on
Aging at Virginia Commonwealth
University.
After this session you will be able to…
• Describe how the POST form can be used as a medical
order set to communicate patient’s end of life care wishes
within and across health care settings.
• Describe the elements of the POST Advance Care Planning
discussion with patients with serious advanced illness or
medical frailty.
• Determine one’s role in the Advance Care Planning
process and develop a system for ensuring that patients in
one’s practice or organization are availed of Advance Care
Planning services.
• Recognize how to make a referral to POST Advance Care
Planning facilitators.
• Participate in Advance Care Planning discussions role play.
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“Death is an inevitable aspect
of the human condition. Dying
badly is not.”
Jennings, et al, 2003
Despite having options . . .this is where we
are with being able to die how and where we
wish . . .
“ 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
But my patient has a living will
and a medical power of attorney--isn’t that enough?
An Index Case
Mr. Jan
What went wrong?
(Could this happen in your facility?)
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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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Let me ask again . . .
In the case of a resident with a terminal or
serious progressive illness, is having a living
will and durable medical power of attorney
enough ?
Living Wills Have Failed to Change
Care at the Bedside
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25% of healthy adults have ADs
50% of people with advanced illness
Completed without guidance
Often not applicable until patients are “terminal”
Focused on a menu of choices rather than desired (and
reasonable) outcomes
• In one study, families accurately stated what was important
to their loved one who had a terminal illness only 50% of
the time.*
• Depression and Impact of Event scores were significantly
lower for bereaved families when they had participated in
Advance Care Planning.**
*Engleberg, R., Patrick, D . & Curtis, J.R. (2005)
** Journal of Pain & Symptom Management March 2007
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Century of Change
Average age of death
Causes of death
Time of disability before
death
1900
2008
47 years of age
78 years of age
Infection
34%
Heart Disease
9%
Cancer
23%
CVA
7%
COPD
6%
Accidents
5%
CVA
5%
Days, weeks
Heart Disease
25%
2 Years average
2008 CDC statistics
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Chronic Disease with Exacerbations
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Evolving Realities
• Increased prevalence of chronic disease
• Increased comorbidities and frailty with medical
advances adding to complexity
• People receive care:
They do not want
From which they cannot benefit
• People fail to receive care:
They do want
From which they will benefit
• Growing perception that death is “optional”
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What is POST?
• POLST Paradigm
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Components of POLST Paradigm
Programs
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Standardized practices and policies
Trained advance care planning facilitators
Timely discussions prompted by prognosis
End-User training for Providers and EMTs
Clear, specific language on an actionable form
Bright form easily found among paperwork
Orders honored throughout the system
QI activities for continual refinement
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What is POST?
• A physician order set
• Can be completed by any
provider or a trained
Facilitator but must be
signed by qualified MD,
DO, NP or PA
• Complements, but does
not replace, advance
directives
POST is designed to honor the freedom of
persons with advanced illness or frailty to have
or to limit treatment across settings of care
POST is Entirely Voluntary:
– No one has to complete a POST
• Choice to have or limit treatments
• Revoke or change at any time
• Comfort measures are always provided
OK, great, but does it work?
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POLST Study-JAGS, June 2014
• Demonstrates value of the POLST Paradigm for
patients with serious illness or frailty.
• Documents relationship between the orders
selected on a POLST Form and the location of
death
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POLST Study-JAGS, June 2014
• Findings:
• Patients with POLST Forms indicating “Comfort
Measures” or “Limited Additional Interventions” are
less likely to die in hospitals than those without.
• Patients with POLST Forms indicating “Full
Treatment/Interventions”: more likely to die in
hospitals than those without POLST.
• These results show that POLST works for both
patients who seek to avoid certain treatments and
for patients who seek every possible intervention.
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POLST Study-JAGS, June 2014
• Conclusion: POLST works for both patients
who seek to avoid certain treatments and for
patients who seek every possible intervention.
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PCPRV Pilot: Transfer and Place of Death
December 2009-May 2011
• N=100 residents at 2 nursing care facilities
• 9 transfers
– 1 to ALF
– 4 to ED (2 for Foley insertion, 1 for GI bleed; other
unknown)
– 2 admitted to hospital (1 died in hospital, other returned
to facility)
– 2 transferred to VAMC Palliative Care unit.
• Place of Death: Only 1 patient with a POST form died in the
hospital
• Residents who died without POST form: 25 % died in hospital
• Implications to hospitals/facilities for readmission scrutiny
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Riverside Health System ACP Outcomes

9 long term care nursing facilities in southeast Virginia with an
average daily census of 718 residents

86 NF residents with POST orders
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It’s about the Conversation
• The form documents a thorough discussion
• Conducted by a trained provider or certified
Facilitator
• Family/Legal decision maker participates
• Focus on goals and desired outcomes
– Based on current condition
– Considers expected complications
– Identifies desired outcomes, unacceptable outcomes
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Conversations That Change
Over Time
People with
Progressive
Illness: guided
planning
Healthy Adults:
Emergency
Planning
Advanced
Illness:
Physician
Orders for
Scope of
Treatment
(POST)
Source: Carol Wilson, Riverside Health System; Used with permission
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Advanced Illness
 Symptoms/likely
complications no longer
hypothetical
 Express preferences for
treatment as medical
orders
 Use POST form in
communities where it is
accepted
“We need to talk about your quality of life,
and what results you want from medical
treatments.”
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POST is for…
 Seriously ill patients
 Those with a chronic,
progressive illness
 Terminally ill patients
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The surprise question
“Would you be surprised if this person died in
the next year?”
If the answer is “no,” a POST form may be the
best documentation of the patient’s informed
choices for medical treatment.
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Role for Physicians:
Promote It--Sign It--Honor It
Identify
patients
Introduce and
normalize ACP
Discuss illness
trajectory
Refer to ACP
Facilitator
OR
Continue ACP
Discussion
Complete or
Review POST
form and
activate
orders
Ongoing
review
• Each
appointment
• Changes in
condition
• After
hospitalization
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Advance Care Planning
Facilitator Training
• Careful discussions that elicit care preferences
ARE the main thing.
• Who will facilitate these discussions ?
– In addition to physicians, RNs, NPs, PAs, Social
Workers and Chaplains who currently do ACP for
their organization/practice
– Non-physician POST ACPFs must be certified in
order to have conversation and assist in POST
form completion
Respecting Choices© POST ACPF
Training
• Designated ACPF training model for Virginia
• Fundraising from state and regional funding sources
(including GTE) for training process.
• Pre-workshop online learning modules + all-day workshop.
• Since 2009, 15 training sessions across the state with
nearly 450 facilitators trained from multiple disciplines
www.respectingchoices.org
Advance Care Planning Facilitators and Trained Providers
THE POST CONVERSATION
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Key to Effective Conversations
• Listen to the patients or patients’
representatives perspective
• Identify gaps, fears, and other barriers to
decision-making
• Explore personal goals and values regarding
remaining life
• Consider what medical care will or will not
help achieve these goals within acceptable
burdens of treatments
Bud Hammes, PhD., 2009 Presentation: Respecting
Choices®, an Advance Care Planning System that Works.
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Set the Stage
• Include family
– Identified Healthcare Agent and define role
• Comfortable setting
– Around a table rather than around a bed
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Facilitators allow 30 minutes
May take place over 2 or more visits
Physician/Facilitator may work as a team
Normalize the planning process
– Important for everyone
• Do not be goal directed
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Assess Understanding of the Illness
• What do you know about your condition?
• What do you know about how this might
change over time?
• Tell me how this is affecting your life right
now.
• Ask permission and fill in gaps as needed
• Active listening
– Reframing, understanding, and empathy
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Explore Experiences
• Experiences with family or friends who
became seriously ill
• Personal experiences
– Recent hospitalizations, etc
• What did that experience mean to you?
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Explore the Concept of “Living
Well”
• What activities or experiences are most important for you
to live well?”
– “What gives life meaning?”
– “What else is most important for you
to live well?”
• What fears or worries do you have about your medical
care?
• What do you hope for during this time?
• “What helps you when you face serious challenges in life?”
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Change Focus to Outcomes
• “We are going to make a plan so that your
quality of life will be as good as it can be.”
• “When someone has your condition, the
treatments don’t always work, and they might
even make you feel worse.”
• “We are going to talk about some of the
treatments that could be provided, what you
can expect from them, and what other choices
there are for you.”
• Understand unacceptable outcomes
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CPR
• One of those treatments is CPR, which is done if
your heart and breathing completely stopped.
• Explore understanding of CPR
• Fill in gaps in understanding
– General success rates for CPR
– Complications
– For someone in your condition ____________
• Patient goals, expected outcomes, unacceptable
outcomes
• Explore fears and concerns
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CPR
• National Conference for Cardiopulmonary
Resuscitation (CPR) and Emergency Cardiac Care
(ECC): Standards for CPR and ECC. JAMA 227:864866, 1974.
– “CPR is not indicated in certain situations, such as cases of
terminal irreversible illness when death is not
unexpected…resuscitation in these circumstances may
represent a positive violation of a person’s right to die with
dignity.”
– Accidental Deaths, e.g. drowning or electrical shock
– Post-MI
Dunn, H. Hard Choices for Loving People, 4th ed. 2001.
CPR
• Shift focus to the positive
– “Everything that is appropriate” for this particular
person at this point in the illness
– Analysis of benefit vs. burden for CPR (each and
every proposed intervention)
– No standardized formula for success, but open
and honest communication improves outcomes
– Provide information for reflection
CPR—Outcome Stats
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CPR outcomes in hospitalized patients
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Fewer than 1 in 5 (17%) patients for whom CPR is
attempted will leave the hospital alive after an average
hospital stay of 2 weeks
Over 30% of these survivors will go to nursing facility or
rehab center
CPR outcomes in long-term care facilities
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Less than 3% survive the CPR attempt
Requires transfer to hospital for mechanical ventilation
and ICU support for complications of CPR
May result in a decline in mental function
Peberdy MA et al. Resuscitation. 58 (2003) 297-308.
Ventilator
• After surgery or after CPR, some people need help to
breathe.
– Goal is to breathe on their own again
– If not, a decision has to be made about when to stop using
the machine
• People with (lung disease, etc.) may get better from a
week or so on a breathing machine.
– Discuss length of time, sedation, hospitalization
• What results would you want, if you needed help with
breathing?
– Find their conditions for stopping treatment
– Discuss palliative alternatives
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Artificial Nutrition
• At a late stage in this illness, people may lose
interest in or the ability to take in food.
– Nutrition through tubes is different from eating
• Useful for people who need strength to get better
• Not helpful for people who are dying from their illness
• Medical consensus that harmful in end stage dementia and
advanced metastatic solid tumor cancer with no ongoing
therapy
– At this stage no sensation of hunger
• We can talk more about this if it becomes an issue
– Do you have any questions or concerns about this?
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Medical Decision-Making
Artificial Nutrition & Hydration
• As the hospice movement gained momentum,
therapies such as ANH that were once applied without
question came under scrutiny. The acute care model of
'universal hydration' then shifted to the hospice model
of 'universal nonhydration.'[4] Some authors have
argued that neither end of the spectrum of ANH use is
appropriate. As healthcare delivery models continue to
evolve, palliative care may reconcile these two ends of
the practice spectrum and identify appropriate uses of
ANH for select groups of patients.[4]
Ersek M. Artificial Nutrition and Hydration: Clinical Issues. Journal of Hospice and Palliative
Nursing. 2003;5(4)
Reference “4:” Bruera E. The Choi and Billings article reviewed. Oncol. 2002; 19:522-523.
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Medical Decision-Making
Artificial Nutrition & Hydration
• Emotionally charged issue
• Benefits for short-term use when function is
temporarily lost
– Dysphagia from CVA
• Benefits for patients who require longer-term use
– Structural cancer
– PVS
• Potential benefits and burdens in the terminally ill
– No recommendation for end stage dementia
– Benefits limited and burdens greater
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Medical Decision-Making
Artificial Nutrition & Hydration
• Potential Burdens of Using ANH
– Increased fluid in the lungs
• Shortness of breath
– Increased fluid in the extremities
• Uncomfortable
• Wounds may weep
– Increased fluid around tumors
• Painful
– Blockage of the body’s ability to make ketones
• Role of ketones
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Medical Decision-Making
Artificial Nutrition & Hydration
• Potential Benefits of Using ANH
– Fluids may be beneficial in some instances, including:
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Delirium
Myoclonus
Diarrhea
Fatigue
• Comfort can be provided whether of not ANH is used
• Language is key
• Provide information for reflection
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Other Treatments
• Antibiotics
– Risk of MRSA, C-diff resulting in isolation, discomfort
– Pneumonia often the last phase of another illness, can
be a comfortable passing
– Describe palliative options
• Dialysis
– Pros and cons, experience of renal failure as last stage,
symptom management
• Other treatments specific to diagnosis
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Quality of Life Issues
• Take note of issues patients have with
hospitalization, nursing homes, etc.
– The quality of life goal heavily influences
treatment preferences
– Many want to avoid hospitalization or nursing
home and will make choices based on that goal
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Hospice
• Patients who want to avoid hospitalizations
should have a consultation with Hospice
“With the choices that you are making, you and
your family would benefit from talking with
someone from hospice. I would like to have
them explain what they can do for you, even if
it is at some later time.”
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Document the Plan on a POST Form
• Review AD (if present). POST and AD’s should
align
• Complete the POST form consistent with the
patient’s preferences
• Sign and date
• Have patient or authorized decision maker
sign
• Make a copy and/or scan into EMR
• Give original to the patient
– Complete DDNR if appropriate
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POST Form Section A
POST Form Section B and C
POST Form Signature
Not Ready?
• Do not partially complete POST; may complete
the process in another appointment
• Reflect planning conversation in physician
notes in EMR
• Complete DDNR if appropriate
• Identify Healthcare Agent as a minimal step,
using AD form or MPOA
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Bottom Line
• POLST Paradigm is achieving its goal of
honoring treatment preferences of those with
advanced illness or frailty.
• POLST/POST serves as catalyst for
conversations in which patients talk with their
loved ones and their health care professionals
about what they really want
– Alvin Moss, MD; Medical Dir. Of Center for Health Ethics and Law of WV University
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Outcomes
• Patients 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 management 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 higher
level of tx than patients with traditional orders.
•
Source: Fromme, E, et al. Association Between Physician Orders for Life-Sustaining Treatment for
Scope of Treatment and In-Hospital Death in Oregon. JAGS 2014
Bringing POST to your facility or practice
• Are you in a POST Pilot Project Region?
– No: Contact the Virginia POST Collaborative about what’s
involved in getting a pilot project going
– Yes: Contact your region’s POST Coalition Coordinator
• Agreeing to standards for site implementation.
– On-site POST coordinator/point person; rep. to regional POST
coalition
– Trained POST Advance Care Planning Facilitators
– Time allocation for facilitators to do Advance Care Planning
– End-user trainings
– Education/outreach to medical directors and PCP’s
– Policies and procedures
– Follow-up QI
POLST: Doing it Better
https://www.youtube.com/watch?v=zlqQgCBCh
n0&feature=youtu.be
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For More Information
• Virginia POST Collaborative:
– www.virginiapost.org
– Chris Pile: Co-Chair; [email protected]
– Matt Kestenbaum: Co-Chair;
mkestenbaum@ capitalcaring.org
– Paula Drummer: Program manager;
[email protected]
• National POLST:
– www.polst.org
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Contact
Email
Regional Pilot
Project Contacts
Region
Charlottesville
Lois Shepherd
[email protected]
Eastern Virginia
Peninsulas
Carol Wilson
[email protected]
Eastern Virginia Southside
David Cochran
[email protected]
Fairfax/NOVA
Matthew
Kestenbaum
[email protected]
Fredericksburg
Rebecca Bigoney
[email protected]
Harrisonburg/Rocking-ham
County
Cindy Harlow
[email protected]
Lynchburg
Patricia Pletke
[email protected]
New River Valley
Karolyn Givens
[email protected]
Rapidan/Rappahannack
Region
Chris Miller
[email protected]
Richmond
Ken Faulkner
[email protected]
Roanoke
Laura Pole
[email protected]
Winchester
Lynn Gray
[email protected]
Augusta County
Dr. Patrick Baroco
[email protected]
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Patient Resources
• The Conversation Project
– theconversationproject.org
• Begin the Conversation
– Begintheconversation.org
• 5 Wishes
– Agingwithdignity.org