Improving Patient-Physician Communication about End-of-Life Care: Virginia POST

1. Improving Patient-Physician Communication about End-of-Life Care: Virginia POST • The Virginia POST Collaborative

2. 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

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

4. 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.

5. 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.

6. 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

7. 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 ?

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

9. 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

10. 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

11. 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

12. 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.

14. Century of Change* *2008 CDC statistics

15. Chronic Disease with Exacerbations

16. 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”

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. Progress of the POLST Paradigm POLST is expanding http://www.ohsu.edu/polst/

29. Regional POST Projects

30. 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

31. Virginia POST Pilot Regions

32. 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 ?

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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