Communications during Life Limiting Illness & POLST in SC

1. Communications during Life Limiting Illness & POLST in SC Walter Limehouse, MD, MA MUSC Ethics Comte

2. Objectives • Identify SC Coalition for Care of Serious Illness (SCC-CSI) • Outline MUSC clinical policy C-169 • Describe POLST in SC: POST

3. Serious Illness Communications • SCMA & SCHA –revisit “medical futility” concern (2010) • SCMA annual meeting resolution, May 2010: • STANDARD COMMUNICATION, CONSENT AND DECISION-MAKING PROCESS FOR SERIOUSLY ILL INPATIENTS IN SOUTH CAROLINA

4. Serious Illness Communications • SCMA House of Delegates, May 2010 • Determine decision-making capacity according South Carolina law; • Determine decision makers or surrogates; • Determine patients’ understanding, beliefs, values, and wishes; • Facilitate effective communication; and • Call palliative care and/or ethics consults to address concerns.

5. SC Coalition for Care of Serious Illness (SCC-CSI) • Charter groups represent diverse state-wide interests • SC Medical Association • SC Nurses Association • SC Hospital Association • SC Healthcare Ethics Network • Carolinas Center for Hospice & End-of-Life Care • SC Society of Chaplains, LifePoint, AARP

6. SCC-CSI Vision Statement • SC delivers excellent communication and shared decision-making for persons with serious, chronic, or terminal illnesses

7. SCC-CSI Initiatives @ MUSC • Improving communications • clinical policy C-169 • Communication Process for Inpatients with Life Limiting Illness • POLST Physician Orders of Life Sustaining Treatment • POST in SC Physician Orders on Scope of Treatment

8. MUSC Clinical Policy C-169 • Communication Process for Inpatients with Life Limiting Illness

9. Life-limiting illness triggers for communications process • Terminal illness with projected death within 6 months • Chronic debilitating illness with readmissions and/or multiple ED visits • Major events, like stroke, resulting in direct ICU admission or transfer • Other illnesses, as so determined by the attending physician

10. Process Facilitator • Nurse case manager or social worker as shepherd • facilitates completion of process forms with medical team • schedules meetings as needed to develop or revise goals of treatment • may document meeting discussions and attendance.

11. Process follows SCMA resolution • Determine decision-making capacity • Determine decision-makers or surrogates • Determine patients’ understanding, beliefs, values, and wishes • Facilitate effective communication and shared decision-making for time interval • Call palliative care and/or ethics consults to address concerns

12. Forms • Serious Illness Planning Progress Note • https://www.musc.edu/cce/ORDFRMS/pdf/all_all_docu_seriousillnessplanningprognote.pdf • Serious Illness Continuing Care Planning Progress Note

13. POLST paradigmPhysician Orders on Life Sustaining Treatment • Physician orders • scope of resuscitative treatment during life threatening emergency • Advance planning with patients • patient death not unexpected within 1 year • Personal physician revises form with patient • upon change of patient condition or choices • annually

14. POLST paradigm Physician Orders on Life Sustaining Treatment • Orders cross institutional boundaries • home, assisted living, skilled nursing facility • EMS pre-hospital • Hospital • emergency department & inpatient • POLST in Action in Oregon (video) • http://www.youtube.com/watch?v=CtrrnAJfT2s&context=C3f17b7bADOEgsToPDskJZLOgVI-NCrNBJSeCyi--I

15. Oregon POLST Form & Process -1991 -Bright Pink -Legally binding for EMS -Valid across institutional boundaries

16. SC EMS DNR Form & Process -Physician order -Legally binding for EMS -Valid only pre-hospital

17. National POLST Paradigm Programs Endorsed Programs Developing Programs *As of February 2012 No Program (Contacts)

18. POLST: POST in SCPhysician Orders on Scope of Treatment • SCC-CSI • organizational home for POST • SC POST form - near ready for adoption. • DHEC - ready to authorize POST pilots • Greenville & Charleston • MUSCMedical Executive Committee • endorses CHARLESTON PILOT OF POST • collaborative initiative with MUSC & Roper

19. POLST:POST in SCPhysician Orders on Scope of Treatment • SCMA annual meeting, April 2012 • resolution endorsing POST being introduced

20. Questions: clinical policy C-169 or POST • Please contact: • Walter Limehouse MD MA • limehouw@musc.edu