POST…. P hysician O rders for S cope of T reatment

1. POST….Physician Orders for Scope of Treatment Respecting Patients’ Wishes at the End of Life Christopher W Pile, MD Section Chief – Palliative Medicine Carilion Clinic

2. Objectives • Describe the need for a system to ensure respect for patients’ wishes • Explain the advantages of the POST form • Discuss the national effort to implement POLST Paradigm Programs • Review the current regional POST Project

3. 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

4. POST is for… Seriously ill patients* Terminally ill patients * chronic, progressive disease/s

5. Broadening Our Understanding ofAdvance Care Planning Advance care planning is a process in which patients… Learn options for care Discuss wishes for care with family and provider Complete advance directives and POST form Have wishes respected when the time comes

6. Patients’ Desires for Treatments in Various Health States (%) Singer et al. J Am Soc Nephrol 1995;6:1410-1417

7. Living Will* Compared to POST • For every adult • Requires decisions about myriad of future treatments • Clear statement of preferences • Needs to be retrieved • Requires interpretation • For the seriously ill • Decisions among presented options • Checking of preferred boxes • Stays with the patient • A physician’s order to be followed *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42.

8. 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

9. The Rationale for POST • AD may not be available when needed • AD may not have prompted needed discussion and may not be specific enough • No provision for treatment in the NH or home • May not cover topics of most immediate need • AD may be overridden by a treating MD • AD does not immediately translate into MD order

10. Prompt for POST Completion Would you be surprised if this patient died in the next year?

11. Components of the System • 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

12. Needed for Completion • Patient with decision-making capacity or • Activation of Medical Power of Attorney • Appointment of Health Care Surrogate • Discussion by physician or designee

13. 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

14. 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

15. POLST is Spreading California, Georgia, Kansas, Missouri, New Mexico, Utah, Virginia, Washington, West Virginia, Wisconsin, New York, North Carolina, Maryland, Pennsylvania * * * * * * * * * * *

16. Validation of POLST • Dunn PM, et al: A method to communicate patient preferences about medically indicated life sustaining treatment J Am Geriatric Soc. 1996;44:785 • Tolle SW, et al: A Prospective study of the efficacy of the POLST J Am Geriatric Soc. 1998;46:1097 • Lee MA, et al: Physician orders for life-sustaining treatment (POLST): Outcomes in a PACE program JAm Geriatric Soc. 2000; 48:1-6. • Hickman SE, Hammes BJ, Moss AH et al. Hope for the Future: Achieving the Original Intent of Advance Directives. Hastings Center Report 2005; Spec No:S26-S30 • Hickman SE, et al. A Comparison of Methods to Communicate Treatment Oreferences in Nursing Facilities: Traditional Practices Vs the POLST Program. J Am Geriatric Soc. 2010; 58: 1241-1248 • Hammes BJ, Rooney BL, Gundrum JD. A Comparative, Retrospective, Observational Study of the Prevalence, Availability, and Specificity of Advance Care Plans in a County that Implemented Advance Care Planning Microsystem. J Am Geriatric Soc. 2010; 58:1249-1255

17. Results: Those 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 mgt. 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 same level of tx as those pts. with traditional orders for full tx.

18. Congruency of PO(L)ST OrdersHickman, et al. JAGS, November 2011 • Study to assess whether the treatments provided were consistent with what was documented on the POLST form. • Reviewed medical records and POLST forms for 870 living and deceased patients

19. Results • Found that POLST orders about resuscitation were honored 98 percent of the time and orders to limit medical interventions were honored 91 percent of the time

20. Bottom Line • POLST/POST 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

21. POST Form

24. Section A: Resuscitation • Only section applicable to EMS • DNR orders only apply if a person is pulseless and apneic • POST recognized as a valid Virginia DDNR • OEMS approval (Michael Berg) 24

25. SectionB • Review care plan to be sure that palliative care measures available • Institute palliative care measures as needed • If meets admission criteria consider hospice

26. Section B: Level of Medical Interventions • Limited Additional Measures • Includes comfort care described in previous section. However, may also use medical treatment, IV fluids, and cardiac monitoring as indicated. • Do not use intubation, advanced airway interventions, or mechanical ventilation. • Transfer to hospital, if indicated. Avoid intensive care. • Full Treatment • Includes care described in 2 previous sections. • Use intubation, advanced airway interventions, mechanical ventilation, and cardiac defibrillation, as indicated. • Transfer to hospital, if indicated. Include intensive care, if indicated.

27. Section B: Level of Medical Interventions • Comfort Measures • Treat with dignity and respect. Keep clean, warm, and dry. • Use medication by any route, positioning, wound care and other measures to relieve pain. • Do not transfer to the hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location.

28. Section C: Antibiotics Example of “Other Instructions”:Antibiotics may be used only as needed for comfort. (E.g., patients susceptible to UTI’s may reserve right to be treated with antibiotic for pain and discomfort.)

29. Section D: Artificial Nutrition/Hydration • These orders pertain to a person who cannot take fluids and food by mouth. • IV Fluids or Feeding Tube for Defined Trial Period: • Gives option of trying either of these to determine benefit to patient and/or for recovery from stroke or hydration from vomiting, etc. • Recommended trial for IV fluids = 2 to 7 days • Recommended trial for Feeding Tube = 30 days or less 29

30. Section E: Participants & Physician Signature 30

31. Related EOL documents, if any, e.g., Living Will Signature of Patient or Legal Representative Signature of ACP Facilitator Directions for Health Care Professionals Section F: POST Reviews & Instructions

32. POST Form Shall Always Accompany Patient/Resident When Transferred or Discharged!* * Note: Preferable to transfer with original current copy, but legible copies are to be honored as though they are the original. On the top of the transfer packet!

33. Regional POST Project: The Roanoke Valley Experience

34. Regional POLST/ACP Project in the Roanoke Valley of Virginia Initiative of Palliative Care Partnership of Roanoke Valley: http://www.pcprv.org/ One hospital, two skilled nursing facilities, and three hospices Clinical and administrative representation from each organization Worked to develop a commonly acceptable POST form

35. Advance Care Planning Facilitator training Respecting Choices curriculum: http://respectingchoices.org/ Fundraising from regional funding sources for training process. Five training sessions with about 175 facilitators trained from multiple disciplines

36. End-User Trainings • 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”

37. Use of the POST Process/Form • Began in December 2009 • Most ACP discussions and POST forms were done in nursing care facilities.

38. Some Interim Results of Pilot Project • End user training for over 600 clinical staff at participating facilities/agencies • 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 id’d and addressed • Patient/Family Satisfaction Surveys: Almost all rate the ACP session favorably

39. Moving POST into Other Areas of Virginia POST State Stakeholders Groups/organizations in 8 additional localities are planning/conducting POST Pilot Projects over the next 2 years Goal: Work with stakeholders and lawmakers to make POST a legally sanctioned document that provides consistency, portability as well immunity to those signing a POST form and those who carry out the orders on the form.

40. Lessons Learned

41. Is the Document Enough? The POST 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 ?

42. Physicians/Providers-the only ones to lead these discussions? Need for non-physician facilitators to lead patient/family discussions, elicit preferences and complete POST forms Facilitators need to be skilled, knowledgeable, and credible to physicians/providers as well as to patients and families

43. Training facilitators is critical Not just cognitive, informational teaching Includes experiential, interactive experience Observed role-playing of ACP discussions

44. Don’t try to do too much initially Start with most pressing patient types (“you wouldn’t be surprised if they died within a year”) Start with select specific “partner” facilities and grow out. Idea of “fertile soil”, “primed facilities”-build upon success incrementally. Change the acceptable “norm” gradually Expand into community as secondary or separate initiative

45. Challenges to change in medical institutions Buy-in clinical/administrative/corporate Physician buy-in requires credible facilitators and process, with physicians/providers ultimately responsible for the POST order they sign.

46. Take-Home Messages • POST provides a better means than AD 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 POST Virginia Stakeholders Task Force

47. Our patients/families are counting on us We and our loved ones are going to age, get sick and die in the medical system of care that we create A motivated group can make even major changes happen over time In your world, if you don’t change things, who will?

48. POST….Physician Orders for Scope of Treatment Questions? cwpile@carilionclinic.org