Are You POST-ing Yet?

Are You POST-ing Yet?Christopher W Pile, MDLaura Pole, RN, MSNTanya Scott, BSWPeter Mellette, EsqWe wish to acknowledge support 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. ObjectivesDescribe the need for a system to ensure respect for patients preferences at the end of lifeReview the National POLST ParadigmReview the current regional POST ProjectsBut my patient has a living will and a medical power of attorney---isnt that enough?

An Index CaseMr. 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. 5After 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;138:812-818.6What went wrong?(Could this happen in Virginia?)Advance directives not documentedDNR order not communicated in transferFragmentation in care (2 hospitals)Overtreatment against patients wishesUnnecessary pain and sufferingSystem-wide failure to respect pts wishesFailure to plan ahead for contingenciesNo system for transfer of plan7Living Wills Have Been Inadequate in Affecting Care at the Bedside25% of healthy adults have ADs50% of people with advanced illnessCompleted without guidanceNot applicable until patients are terminalFocused on a menu of choices rather than desired (and reasonable) outcomesIn 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

8Let me ask again . . .In the case of a person with a terminal or serious progressive illness, is having a living will and durable medical power of attorney enough ?

Conversations that change over time

Source: Carol Wilson, Riverside Health System; Used with permissionHealthy Adults

Name a Healthcare AgentPrepare for sudden injury or eventComplete basic Advance Directive

Source: Carol Wilson, Riverside Health System; Used with permissionProgressive Illness

Understand potential complications and treatment optionsConsider benefits and burdens of end of life treatmentsDiscuss preferences with familyMake Advance Directive more specificRe-evaluate goals with changes in conditionSource: Carol Wilson, Riverside Health System; Used with permission

Late Stage IllnessNo longer hypotheticalExpress preferences for treatment as medical ordersUse POST form in communities where it is accepted

Source: Carol Wilson, Riverside Health System; Used with permission

Living Will* Compared to POSTFor every adultRequires decisions about myriad of future treatmentsRequires interpretationNeeds to be retrievedFor the seriously illDecisions among presented optionsMedical orders which turn a patients values into actionFollows patient across settings of care on consistent document*Fagerlin & Schneider. Enough: The Failure of the Living Will.Hastings Center Report 2004;34:30-42.

Century of Change*19002008Average age of death47 years of age78 years of ageCauses of deathInfection 34% Heart Disease 25% Heart Disease 9% Cancer 23% CVA 7% COPD 6% Accidents 5% CVA 5% Time of disability before deathDays, weeks2 Years average*2008 CDC statisticsChronic Disease with Exacerbations

Evolving RealitiesIncreased prevalence of chronic diseaseIncreased comorbidities and frailty with medical advances adding to complexityPeople receive care: They do not want From which they cannot benefit People fail to receive care:They do want From which they will benefitDeath is optional18The end-of-life has changed dramatically in recent years as life expectancies have increased, chronic disease rates have risen, and families, the health care systems and society have changed. As technology has advanced, death has become viewed by society as failure and optional.Too often, death is viewed as a medical failure rather than the final chapter of life. As a result, people have come to fear a technologically overtreated and protracted death, abandonment and profound suffering for self and family. Conversation about death is avoided in families and with providers until a crisis occurs, resulting in inadequate advance care planning and patient preferences not being honored. Hospice care is introduced late and inadequate palliation provided. We canand mustdo better.

Key to Effective ConversationsListen to the patients or patients representatives perspectiveIdentify gaps, fears, and other barriers to decision-makingExplore personal goals and values regarding remaining life Consider what medical care will or will not help achieve these goals within acceptable burdens of treatmentsBud Hammes, PhD., 2009 Presentation: Respecting Choices, an Advance Care Planning System that Works. 21Resources for The ConversationThe Conversation Projectwww.theconversationproject.org

Respecting Choiceswww.respectingchoices.org

What is POST?A physician orderCan be completed by any provider but must be signed by qualified MD or DOComplements, but does not replace, advance directives Voluntary usePOST 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 POSTChoice to have or limit treatmentsRevoke or change at any timeComfort measures are always provided

24Purpose of POSTTo provide a mechanism to communicate patients preferences for end-of-life treatment across treatment settingsTo improve implementation of advance care planningEnsure care delivered reflects patients preferences, values, and goalsPOST is forSeriously ill patients*Terminally ill patients* chronic, progressive disease/sWhy POST WorksTransfers across care settingsContains specificsIt IS a physicians orderno interpretation is needed and POST orders are to be followedComponents of the POLST ParadigmStandardized practices and policiesTrained advance care planning facilitatorsTimely discussions prompted by prognosisClear, specific language on an actionable formBright form easily found among paperworkOrders honored throughout the systemQI activities for continual refinementPOLST began in Oregon in 1991A System-wide ApproachDifferent settingsNursing HomeHomeEMSHospitalUniform responseDocument that indicates specific responses to various likely complicationsAvoidance of getting it wrongFailure of planned action to be completed as intendedAMDA Weighs InWe welcome additional data and new models of care that will help us create and evolve optimal processes for transitions between care settings. In the meantime, we propose some basic tenets that we believe, at least intuitively, will serve as underpinnings to enhance safe and efficient transitions . . .

AMDA Supports the POST ProcessConsistent discussion and documentation of advance directives and end-of-life care preferences, with up-to-date PO(L)ST forms or, in states where these are not available, with other appropriately executed advance directive forms.Developing ProgramsNational POLST Paradigm ProgramsEndorsed ProgramsNo Program (Contacts)

*As of February 201332

Regional POST ProjectsRegional POST/ACP ProjectRoanoke Valley

Initiative of Palliative Care Partnership of Roanoke Valley:http://www.pcprv.org

One hospital, two skilled nursing facilities, and three hospicesClinical and administrative representation from each organizationWorked to develop a commonly acceptable POST form37

Is the Document Enough?The POLST form is an essential element of a system to document and transmit patient care preferences, but it is not the MAIN thing. Careful discussions that elicit care preferences ARE the main thing.

Who will facilitate these discussions ?Designated ACPF training model for VirginiaFundraising from state and regional funding sources (including GTE) for training process.Pre-workshop online learning modules + all-day workshop.15 training sessions with nearly 450 facilitators trained from multiple disciplines

Respecting Choices POST ACPFTraining

In Virginia, weve chosen the Respecting Choices POST Advance Care Planning Facilitator Training as the gold standard for training. As long as we are conducting POST pilot projects, this is the training we will require our Advance Care Planning Facilitators to have.40End-User TrainingInservice 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 liveThousands of end-users training in pilot regions

Problem: Few physicians have time to participate in RC TrainingGTE Grant: Develop, pilot and refine a one-hour training for physicians caring for POST-appropriate patients.Theme: Promote It, Sign It, Honor ItPresentations began May 2013; plan to offer in pilot project regions in the upcoming year.CME credits grantedTraining for PCPsPCP = Primary Care Provider (Physician)42Began in December 2009Most ACP discussions and POST forms were done in nursing care facilitiesQI data collected from medical records of nearly 100 residents/patients with POST forms:98% congruency between orders written and care delivered

Roanoke Pilot Project QI9 transfers1 to ALF4 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 an acute care unit in the hospitalResidents who died without POST form: 25 % died in acute care setting in hospitalImplications to hospitals/facilities for readmission scrutiny

Transfer and Place of DeathAre you in a POST Pilot Project Region?No: Contact Laura Pole about whats involved in getting a pilot project goingYes: Contact your regions POST Coalition Coordinator (see list on last 2 slides)Agreeing to standards for site implementation.On-site POST coordinator/point person; rep. to regional POST coalitionTrained POST Advance Care Planning FacilitatorsTime allocation for facilitators to do Advance Care PlanningEnd-user trainingsEducation/outreach to medical directors and PCPsPolicies and proceduresFollow-up QIBringing POST to your facilityBottom LinePOLST Paradigm is achieving its goal of honoring tx preferences of those with advanced illness or frailty.Plus----POLST/POST serves as catalyst for conversations in which pts. talk with their loved ones and their health care professionals about what they really wantAlvin Moss, MD; Medical Dir. Of Center for Health Ethics and Law of WV UniversityParticipating in POSTIn TheNursing HomeTanya Scott, BSWWhat Is The Next Step?Decide to participate in POST

Who are key players in facilities?

Who can be champions for POST?

Take-Home MessagesPOST provides a better means than AD alone to identify and respect patients wishesPOST completion will improve end-of-life care throughout the systemUse of POST will require communication to make it work in your communityConsider joining the Virginia POST Collaborative Statewide Advisory CommitteeConsider participating in a Regional POST Project

National POLST Paradigm: www.polst.orgVirginia POST Collaborative: www.virginiapost.orgNational Hospice Foundation: www.hospiceinfo.orgNational Hospice and Palliative Care Organization: www.nhpco.orgPalliative Care Partnership of the Roanoke Valley: www.pcprv.orgHard Choices for Loving People by Hank Dunn

Using your resources:National POLST Paradigm: www.polst.orgVHHA: http://www.vhha.com/healthcaredecisionmaking.htmlNHPCO: Caring Connections: http://www.caringinfo.orgNational Health Care Decisions Day: http://www.nhdd.org/Resources for Advance Care PlanningFor More InformationVirginia POST Collaborative:Chris Pile: cpile@goodsamhospice.orgLaura Pole: Lpchef@earthlink.net www.virginiapost.orgNational POLST:www.polst.org54Regional Pilot Project ContactsRegionContactEmailCharlottesvilleLois ShepherdLLS4B@hscmail.mcc.virginia.eduEastern Virginia PeninsulasCarol WilsonCarol.Wilson@rivhs.comEastern Virginia SouthsideDavid CochranDACOCHRA@sentara.comFairfax/NOVAMatthew Kestenbaummkestenbaum@capitalcaring.orgFredericksburgRebecca Bigoneyrebecca.bigoney@mwhc.comHarrisonburg/Rocking-ham CountyCindy Harlowcharlow@rhcc.comLynchburgPatricia PletkePatricia.Pletke@centrahealth.comNew River ValleyKarolyn Givenskgivens@RADFORD.EDURapidan/Rappahannack RegionChris Millercmiller@agingtogether.orgRichmondKen Faulknerkafaulkn@vcu.eduRoanokeLaura PoleLpchef@earthlink.netWinchesterLynn Graylgray@blueridgehospice.orgAugusta CountyDr. Patrick BarocoPBaroco@AugustaHealth.com55