improving patient-physician communication about end-of-life care: virginia post
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Improving Patient-Physician Communication about End-of-Life Care: Virginia POST. The Virginia POST Collaborative. Objectives. Describe the need for a system to ensure respect for patients’ preferences at the end of life Review the National POLST Paradigm - PowerPoint PPT PresentationTRANSCRIPT
Improving Patient-Physician Communication about End-of-Life Care: Virginia POST
The Virginia POST Collaborative
1
Objectives Describe the need for a system to
ensure respect for patients’ preferences at the end of life
Review the National POLST Paradigm Review the current regional POST
Projects
But my patient has a living will and a medical power
of attorney---isn’t that enough?
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.
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.
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
Let 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 permission
Healthy Adults: Emergency Planning
People with Progressive Illness: guided planning
End Stage Illness: Physician Orders for Scope of Treatment
Healthy Adults
Name a Healthcare Agent
Prepare for sudden injury or event
Complete basic Advance Directive
Source: Carol Wilson, Riverside Health System; Used with permission
Progressive Illness Understand potential
complications and treatment options
Consider benefits and burdens of end of life treatments
Discuss preferences with family
Make Advance Directive more specific
Re-evaluate goals with changes in condition
Source: Carol Wilson, Riverside Health System; Used with permission
Late Stage Illness
No longer hypothetical
Express preferences for treatment as medical orders
Use POST form in communities where it is accepted
Source: Carol Wilson, Riverside Health System; Used with permission
Living Will* Compared to POST
For every adult Requires decisions about myriad of
future treatments Requires interpretation Needs to be retrieved
For the seriously ill Decisions among presented options Medical orders which turn a patient’s
values into action Follows 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*1900 2008
Average age of death 47 years of age 78 years of age
Causes of death Infection 34% Heart Disease 25%
Heart Disease 9% Cancer 23% CVA 7% COPD 6%
Accidents 5% CVA 5%
Time of disability before death
Days, weeks 2 Years average
*2008 CDC statistics
Chronic Disease with Exacerbations
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
Death is “optional”
What is POST? A physician order Can be completed by any
provider but must be signed by qualified MD or DO
Complements, but does not replace, advance directives
Voluntary use
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
Ensure care delivered reflects patient’s preferences, values, and goals
POST is for…Seriously ill patients*Terminally ill patients* chronic, progressive disease/s
Why POST Works Transfers across care settings Contains specifics It IS a physician’s order—no
interpretation is needed and POST orders are to be followed
Components of the POLST Paradigm
Standardized practices and policies Trained advance care planning facilitators Timely discussions prompted by prognosis Clear, specific language on an actionable
form Bright form easily found among paperwork Orders honored throughout the system QI activities for continual refinement
A System-wide Approach Different settings
Nursing Home Home EMS Hospital
Uniform response Document that indicates specific
responses to various likely complications Avoidance of “getting it wrong”
Failure of planned action to be completed as intended
Progress of the POLST Paradigm
POLST is expanding http://www.ohsu.edu/polst/
Regional POST Projects
Regional 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 organization
Worked to develop a commonly acceptable POST form
Virginia POST Pilot Regions
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 ?
ACP Facilitator Training
Respecting Choices curriculum:http://respectingchoices.org/
Fundraising from regional funding sources for training process.
12 training sessions with nearly 400 facilitators trained from multiple disciplines
End-User Training 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”
Thousands of end-users training in pilot regions
QI Results of Roanoke Pilot Project
Began in December 2009 Most ACP discussions and POST forms were done
in nursing care facilities 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 addressed
Patient/Family Satisfaction Surveys: Almost all rate the ACP session favorably
Transfer and Place of DeathDecember 2009-May 2011
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
Moving POST into Other Areas of Virginia
Virginia POST Collaborative Executive Committee Statewide Advisory Committee
Groups/organizations in 3 additional regions are planning/conducting POST Pilot Projects over the next 2 years
Goal: Work with stakeholders and lawmakers to: Make POST the standard practice Provides consistency, portability as well
immunity to those signing a POST form and those who carry out the orders on the form
Bottom Line POLST 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 want”
Alvin Moss, MD; Medical Dir. Of Center for Health Ethics and Law of WV University
Take-Home Messages POST provides a better means than AD
alone 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 Virginia POST Collaborative Statewide Advisory Committee
Consider participating in Charlottesville Pilot