post - a better means for communicating end of life care wishes
TRANSCRIPT
Laura Pole, RN, MSN, OCNS
Virginia POST Collaborative
“Death is an inevitable aspect of the human condition.
Dying badly is not.”
Jennings, et al, 2003
Need for more specific advance care planning at the end of life.
The process of making POST available in Virginia as a communication tool for end of life care wishes.
How POST is affecting end of life care at the bedside.
Resources
An Index Case
Mr. Jan
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
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 ?
Healthy
Adults:
Emergency
Planning
People with
Progressive
Illness:
guided
planning
End Stage
Illness:
Physician
Orders for
Scope of
Treatment
Name a Healthcare Agent
Prepare for sudden injury or event
Complete basic Advance Directive
Source: Carol Wilson, Riverside Health System; Used with permission
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
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
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.
No specific end of life care orders means patients want full interventions. ◦ Maybe, maybe not . . .
◦ And what’s the default if the patient can’t tell you?
A DNR order means a patient doesn’t want more than comfort measures.
DNR Status is not a predictor of the care patients wish for at the end of life—many with DNR chose limited or full interventions as well as artificial nutrition.
PO(L)ST is a neutral form—allows patients to have or limit treatment.
PO(L)ST reduces making assumptions based on DNR status alone.
Fromme, E.K. Zive, D., Schmidt, T.A., Olszewski, E. & Tolle, S.W. (2012). POLST Registry, Do-Not-Resuscitate orders and other patient
treatment preferences. Journal of the American Medical Association, 307(1), 34-35.
2007 2008 2009 2010 2011 2012 2013
History of POST in Virginia
IDEA +1 Local Pilot Project State Stakeholders
Grant & In-Kind Support
+ =
Virginia POST Collaborative
&13 Regional POST
Programs
Clear Message: Who is appropriate for POST?
Becoming a participating pilot project region.
Advance Care Planning Facilitator Training
PCP Training
End-User Training
Public Education
POST is for:Seriously ill patients*Terminally ill patientsThose with advanced frailty
Gives options to limit or have care
VoluntaryCan be revoked or changedComfort measures always offered
* chronic, progressive disease/s
◦ Ongoing training, mentoring and support
◦ POST Pilot Project Training Webpage
◦ Training webinars and presentations
◦ One-on-one consultation
Careful discussions that elicit care preferences ARE the main thing.
Who will facilitate these discussions ?◦ Non-physician POST ACPF’s must be certified in
order to have conversation and assist in POST form completion
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. 15 training sessions with nearly 450 facilitators
trained from multiple disciplines
Problem: Few physicians have time to participate in RC Training
GTE Grant: Develop, pilot and refine a one-hour training for physicians caring for POST-appropriate patients.
Theme: Promote It, Sign It, Honor It Presentations scheduled for May and June
2013 CME credits granted Future: Conduct train the trainer so that
regional pilots can host these trainings.
For care providers who are likely to come in contact with a patient with a POST form.
Participating hospitals, nursing care facilities, hospices, EMS, and other care settings.
GTE Funding to refine template presentations in multiple formats:◦ Live presentations
◦ Online self-paced module
Thousands of end-users trained in pilot regions.
Primarily limited to pilot project regions.
Growing interest and multiple requests from patients/families
Virginia POST Website: ◦ Funding from National POLST, GTE and a hospital
system.
◦ Full website up and running by Summer 2013
Skilled Trained Facilitators
Laws, Statutes, Regulations
Uniform Policies, Procedures, Standards
POST Form
Can Care Settings Provide Competent, Compassiona
te Palliative Care?
Collaborative Stakeholders
and Coalitions
Resources
Webpage and Communication Plan
Physician Support
Advocacy Plan
Roanoke Valley Pilot Project QI Study
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:◦ 98% congruency between orders written and care
delivered
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 an acute care unit in the hospital
Residents who died without POST form: 25 % died in acute care setting in hospital
Implications to hospitals/facilities for readmission scrutiny
PO(L)ST is achieving its goal of honoring txpreferences of those with advanced illness or frailty.
Plus----PO(L)ST serves as an ACP conversation catalyst”
Review:◦ Where POST is in Virginia
◦ Contacting your Region’s POST Pilot Project Coordinator
No Pilot in Your Area?◦ Contact Laura Pole ([email protected]) for
guidelines on implementing POST in your community
National POLST Paradigm: www.polst.org
Virginia POST Collaborative: www.virginiapost.org
• National Hospice Foundation: www.hospiceinfo.org
• National Hospice and Palliative Care Organization: www.nhpco.org
• Palliative Care Partnership of the Roanoke Valley: www.pcprv.org
• “Hard Choices for Loving People” by Hank Dunn
National POLST Paradigm: www.polst.org
VHHA: http://www.vhha.com/healthcaredecisionmaking.html
NHPCO: Caring Connections: http://www.caringinfo.org
National Health Care Decisions Day: http://www.nhdd.org/
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 requires communication to make it work in your community
Local, Regional and Statewide collaboration is pivotal to making POST available as a uniform, portable and legal document and process.
We could make it holy.
