The NC MOST Form: What’s in it for LTC facilities, patients families & providers?

1. The NC MOST Form:What’s in it for LTC facilities, patients families & providers? NC Health Care Facilities Association Webinar August 2, 2012

2. With thanks to contributors… Anthony J. Caprio, MD Assistant Professor of Medicine Division of Geriatric Medicine Center for Aging and Health Palliative Care Consultation Service University of North Carolina- Chapel Hill John C. Ropp, III, MD, Chairman, SC CSI

3. “In my day, people died.”

4. The Problem • Too many people are dying in places they would not choose, in ways they would not want, surrounded by strangers, their wishes undocumented, unknown and, therefore, often not honored. • What we say we want is not what we get. In fact, what we get is often the exact opposite of what we would want.

5. Statistics • ~80% wish to die at home • Over 85% say they want spiritual needs met • Over 90% want well-managed pain • ~25% die at home • ~6% have talked to their minister • ~11% have talked to their MD

6. What has gone wrong? • The conversation is not taking place. Why? • Medicare (via PSDA) says “We’ll give you money if you have the conversation.” • Reality is “We’ll take the money and hand out the documents.” • Wrong place, wrong time, wrong person, wrong mechanisms. • Current EOL Care often does not reflect patients’ values and preferences. • EOL Care costs a lot of money compared to other healthcare expenditures.

8. Language & setting matter…. • “Would you like information about advance directives?” (Pt: “What does THAT mean?) • “I need a copy of your Living Will” (WHY?) OR • “We want to provide you with the best care possible. These documents will help us understand and honor your wishes.” • “Have you talked with your family & physician about the kind of care you want? This information may help.”

9. Conveyor Belt?? • You may have a good relationship with your PCP, however….. • Count the number of specialists and treatment settings the patient encounters….. • Stepping into a modern day emergency center is like stepping onto a moving train. David Blackmon, MDiv, Asheville, NC

10. Treatment settings • Outpatient settings • Emergency rooms • ICU • Step-down units – hospitalists • Med/Surg units • Rehab • Palliative care • LTC • Hospice

11. What happens in the ED? • Why is this patient here? • What does this patient want? • How aggressive should we be? • Do I intubate this patient? • Who is involved in this patient’s care? • What is the appropriate disposition?

12. Limitations of Advance Directives • May not be available when needed • May not be specific enough • Does not translateimmediately into medical order Literature Review on Advance Directives, June 2007 http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm

13. It’s not about the documents! It’s about the conversation.It’s about the patient’s right to choose.How do we communicate our wishes?

16. Technology of Critical Care www.icu-usa.com/tour

18. Treatment Options • CPR • Artificial hydration • Artificial nutrition • Artificial ventilation • Antibiotics • Dialysis • Chemo/radiation therapy • Pharmaceuticals • Pace makers

19. Should ‘everything’ be done? Knowledge Wisdom

20. When is Enough Enough?The Ethics of Over-treating or Under-Treating Patients at the End of Life: Do good; Do no harm; Prevent harm Right vs. Risk Is it time for us to look at what we are doing and why we are doing it?

21. What does all this have to do with the National POLST Paradigm and the NC MOST form?EVERY THING!

22. Basis of POLST Encourages discussion about key end of life care issues

23. POLST Paradigm Purpose The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm program is designed to improve the quality of care people receive at the end of life. It is based on effective communication of patient wishes, documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes. It is a win-win for all involved.

24. National POLST Paradigm A win-win for everyone

25. POLST History • 1991 - Patient Self Determination Act • 1991 - POLST form developed in Oregon • 2002 - POST in West Virginia • 2007 - MOST in North Carolina

26. POLST Paradigm 1990

27. National POLST Paradigm Programs* Endorsed Programs *As of January 2011 Developing Programs No Program (Contacts) Designation of POLST Paradigm Program status based on information available by the program to the Task Force.

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

29. What fueled the spread of the POLST Paradigm?

30. Do Not Resuscitate (DNR) Order Medical Order Issued by a physician (NP or PA) Not hypothetical; immediately “in effect” No interpretation, immediately directs care in the event of a cardiac arrest

31. Beyond Resuscitation Except in the event of cardiopulmonary arrest, resuscitation orders do not direct other treatments Some patients desire an attempt of resuscitation but want to limit other types of treatment DNR does not necessarily imply other treatment limitations (DNR ≠ Do Not Treat) What other kinds of treatments might the patient receive (or not receive) if they had a DNR order? Tanabe M. Annals of Long Term Care 2004;12:42-45 Zweig SC, et al. J Am Geriatr Soc.Jan 2004;52(1):51-58. Hickman SE, et al. J Am Geriatr Soc 52:1424–1429, 2004.

32. Medial Orders for Scope of Treatment (MOST) form More than a DNR order Guide care even when patient has not arrested Options to receive or withhold treatments Avoid inappropriately limiting or providing other types of treatments

33. Pink MOST Form • Identifiable: consistent pink color • Flexible: allows accepting or refusing treatments • Actionable: medical orders • Up-to-date: reviewed regularly • Portable: transfer across health care settings

34. MOST: 5 Sections • Cardiopulmonary Resuscitation (CPR) • Medical Interventions • Antibiotics • Medically Administered Fluids & Nutrition • Discussed with and agreed to by…

35. Section A: CARDIOPULMONARY RESUSCITATION • Attempt Resuscitation (CPR) • Do Not Attempt Resuscitation (DNR/no CPR) • Only one option should be selected. • Only applies if there is no pulse and the patient has stopped breathing (cardiopulmonary arrest)

36. Survival After Cardiopulmonary Resuscitation (CPR) • Generally, only 10-15% survive to hospital discharge; many with impairments • Lower rates of survival (<5%) • Unwitnessed arrest • Certain types of heart rhythms • Multiple chronic diseases • Survival for nursing home patients 0-3%

37. Inaccurate Perceptions of Survival • General belief of 65% survival after CPR • 67% of resuscitations successful on TV • Probability of survival influences choices • Nearly one-half of older adults changed their mind about wanting CPR after hearing about the true probability of survival NEJM 1996: 334:1578-1582 NEJM 1994; 330:545-549

38. Goals of Medical Care • Prioritized goals provide context for medical decision making • Longevity • Function (maintain/restore) • Comfort • Rarely, can all three goals be maximized simultaneously • As clinical circumstances change, goals are reprioritized J Am Geriatr Soc 1999;47(2):227-230

39. Section B: MEDICAL INTERVENTIONS • Full Scope of Treatment • Limited Additional Interventions • Comfort Measures • Guidance about the intensity of care and the patient’s goals • Patient is not experiencing cardiopulmonary arrest (No indication for CPR)

40. Prioritize Goals of Care • Longevity • Function (maintain/restore) • Comfort J Am Geriatr Soc 1999;47(2):227-230

41. Full Scope of Treatment • Intubation/mechanical ventilation • Cardioversion • ICU admission • Transport to the hospital if indicated • All other appropriate treatments • Patients electing “Full Scope” usually express longevity as the primary goal of care

42. Limited Additional Interventions • No intubation/mechanical ventilation • No cardioversion • Would likely not be admitted to the ICU • Transport to the hospital if indicated • “Other instructions” can be used for clarifications • Goals of Care • Usually do not prioritize longevity as their major goal • May express other goals like maintaining or restoring function • May opt for therapeutic trials and withdraw therapies if they are ineffective or become burdensome

43. Comfort Measures • These patients prioritize comfort as their most important goal of care • Care is focused exclusively on relieving distressing symptoms • No intubation/mechanical ventilation • No cardioversion • No ICU admissions • Transport to the hospital ONLY if comfort needs can not be met in the current location

44. Section B POLST users with Comfort Measures only • 67% less likely to receive life sustaining medical interventions compared to POLST full treatment. • Research shows that most people select “limited additional interventions.” P<0.004

45. Section C:ANTIOBIOTICS • To receive antibiotics if life can be prolonged • To determine use or limitation of antibiotics when infection occurs • No antibiotics, in which case other measures would be used to relieve symptoms

46. Section D:MEDICALLY ADMINSTERED FLUIDS AND NUTRITION • IV fluids options: • To receive if indicated • To receive for a defined trial period • No IV fluids • Feeding tube options: • To receive if indicated • To receive for a defined trial period • No feeding tube

47. Nutrition and HydrationBenefits and Burdens • Often religious and cultural beliefs guide a patient’s decision • Discussed in the context of goals of medical care • IV fluids may not promote comfort at the end of life • Swelling • Shortness of breath • Need for frequent urination. • Excessive secretions • Feeding Tube decisions are complex • Promotes longevity in some cases (ie. brain injury) • No clear survival benefit in advanced dementia • Comfort care measures: ice chips and mouth care

48. Trial Periods or Time-Limited Trials • Not starting and stopping are equivalent • Emotionally, stopping is often more difficult • When goal is not achieved, shift focus • Sometimes difficult to define duration

49. Section E:DISCUSSED WITH AND AGREED TO BY: • Patient • Parent or guardian if patient is a minor • Health care agent • Legal guardian • Attorney-in-fact with power to make health care decisions • Spouse • Majority of patient’s reasonably available parents and adult children • Majority of patient’s reasonably available adult siblings • An individual with an established relationship with the patient who is acting in good faith and can reliably convey the wishes of the patient

50. Revocation of MOST • MOST no longer reflects patient’s preferences • Put line through the front page and write “void” • “Form VOIDED” in the Review section on back of MOST • New form completed • No new form Void