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Are You “POST- ing ” Yet?. Christopher W Pile, MD Laura Pole, RN, MSN Tanya Scott, BSW Peter Mellette, Esq.

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Are You “POST- ing ” Yet?

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Are you post ing yet

Are You “POST-ing” Yet?

Christopher W Pile, MD

Laura Pole, RN, MSN

Tanya Scott, BSW

Peter Mellette, Esq


Are you post ing yet

We 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.


Objectives

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

But my patient has a living will and a medical power of attorney---isn’t that enough?


Are you post ing yet

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.


Are you post ing yet

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

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


Living wills have been inadequate in affecting care at the bedside

Living Wills Have Been Inadequate in Affecting Care at the Bedside

  • 25% of healthy adults have ADs

  • 50% of people with advanced illness

  • Completed without guidance

  • Not applicable until patients are “terminal”

  • Focused on a menu of choices rather than desired (and reasonable) outcomes

  • In 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


Let me ask again

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 ?


Are you post ing yet

Conversations that change over timeSource: Carol Wilson, Riverside Health System; Used with permission


Healthy adults

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

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

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

Living Will* Compared to POST

*Fagerlin & Schneider. Enough: The Failure of the Living Will.

Hastings Center Report 2004;34:30-42.


Are you post ing yet

Century of Change*

*2008 CDC statistics


Chronic disease with exacerbations

Chronic Disease with Exacerbations


Evolving realities

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”


Key to effective conversations

Key to Effective Conversations

Bud Hammes, PhD., 2009 Presentation: Respecting Choices®, an Advance Care Planning System that Works.

  • Listen to the patients’ or patients’ representatives’ perspective

  • Identify gaps, fears, and other barriers to decision-making

  • Explore personal goals and values regarding remaining life

  • Consider what medical care will or will not help achieve these goals within acceptable burdens of treatments

21


Resources for the conversation

Resources for The Conversation

  • The Conversation Project

    • www.theconversationproject.org

  • Respecting Choices

    • www.respectingchoices.org


What is post

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


Are you post ing yet

POST 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 POST

      • Choice to have or limit treatments

      • Revoke or change at any time

      • Comfort measures are always provided


Purpose of post

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

POST is for…

Seriously ill patients*

Terminally ill patients

* chronic, progressive disease/s


Why post works

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

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

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


Amda weighs in

AMDA Weighs In

  • “We 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 process

AMDA Supports the POST Process

  • Consistent 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.


Are you post ing yet

National POLST Paradigm Programs

Endorsed Programs

Developing Programs

*As of February 2013

No Program (Contacts)


Regional post projects

Regional POST Projects


Regional post acp project roanoke valley

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 hospices

Clinical and administrative representation from each organization

Worked to develop a commonly acceptable POST form


Is the document enough

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 ?


Respecting choices post acpf training

Respecting Choices® POST ACPFTraining

  • 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


End user training

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


Training for pcp s

Training for PCP’s

  • 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 began May 2013; plan to offer in pilot project regions in the upcoming year.

  • CME credits granted


Roanoke pilot project qi

Roanoke Pilot Project QI

  • 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


Transfer and place of death

Transfer and Place of Death

  • 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


Bringing post to your facility

Bringing POST to your facility

  • Are you in a POST Pilot Project Region?

    • No: Contact Laura Pole about what’s involved in getting a pilot project going

    • Yes: Contact your region’s 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 coalition

    • Trained POST Advance Care Planning Facilitators

    • Time allocation for facilitators to do Advance Care Planning

    • End-user trainings

    • Education/outreach to medical directors and PCP’s

    • Policies and procedures

    • Follow-up QI


Bottom line

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


Participating in post in the nursing home

Participating in POSTIn TheNursing Home

Tanya Scott, BSW


What is the next step

What Is The Next Step?

  • Decide to participate in POST

  • Who are key players in facilities?

  • Who can be champions for POST?


Take home messages

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 a Regional POST Project


Using your resources

Using your resources:

  • 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


Resources for advance care planning

Resources for Advance Care Planning

  • 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/


For more information

For More Information

  • Virginia POST Collaborative:

    • Chris Pile: [email protected]

    • Laura Pole: [email protected]

    • www.virginiapost.org

  • National POLST:

    • www.polst.org


Regional pilot project contacts

Regional Pilot Project Contacts


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