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HEALTH CARE PLANNING: EVOLVING PRACTICES, INNOVATIVE APPROACHES

HEALTH CARE PLANNING: EVOLVING PRACTICES, INNOVATIVE APPROACHES. GARY L. STEIN, JD, MSW Associate Professor Wurzweiler School of Social Work Yeshiva University. HEALTH CARE PLANNING. Why is it important? Protect your rights Maintain control over one’s care

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HEALTH CARE PLANNING: EVOLVING PRACTICES, INNOVATIVE APPROACHES

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  1. HEALTH CARE PLANNING:EVOLVING PRACTICES, INNOVATIVE APPROACHES GARY L. STEIN, JD, MSW Associate Professor Wurzweiler School of Social Work Yeshiva University

  2. HEALTH CARE PLANNING • Why is it important? • Protect your rights • Maintain control over one’s care • Assure your choice of who makes decisions • Assure your preferences for care are respected • Better inform surrogates & providers of wishes

  3. EVOLUTION OF ADVANCE CARE PLANNING • Legal Transactional Approach • Focus on formal legal documents • Paradigm for state advance directive laws • Communications Approach • Focus on flexible, ongoing discussions with family & providers • Charles Sabatino (2009). “The Evolution of the Health Care Advance Directive Law and Policy,” unpublished.

  4. LEGAL TRANSACTIONAL APPROACH • Issue for planning: • Patients may only be treated with consent • Incapacitated patients cannot make decisions • Process needed to make decisions about care when capacity is lacking

  5. PLANNING TOOLS: LIVING WILL • Express wishes about life-sustaining care • CA, 1976; most states now • Withhold / withdraw care • Preconditions: • Terminal illness • Permanent unconscious state • Physician immunity for complying in good faith

  6. PLANNING TOOLS:APPOINTING SURROGATE • Living wills focus narrowly • Appointment of agent to act for patient • Power of Attorney for Health Care or Health Care Proxy • CA, 1983 • All states, 1997

  7. COMBINED TOOLS • Create clarity • Merges living will & proxy in single directive • NJ, 1991; half states now

  8. OUT-OF-HOSPITAL DNR • Unwanted resuscitations when living at home • EMS called during medical crisis • Obligation to resuscitate • DNR order for EMS • Identifier on pt or posting • Protocols in most states

  9. DEFAULT CONSENT LAWS • When no appointed surrogate or guardian • Listing of default surrogates • Ex: Spouse, adult child, parent, adult sibling, other adult relatives, adult friends • Exist in approx. 40 states • Issue for same-sex partners

  10. ISSUE: “UNBEFRIENDED PATIENTS” • Lacking close family or friends to make decisions • Creative solutions needed

  11. PATIENT SELF-DETERMINATION ACT • Patient/public education requirements • US, 1990 • Medicare/Medicaid providers • Written notification of state rights for advance directives • Document • Staff/community education • Varying experiences of effectiveness

  12. How Do We Do? (U.S.) • 53%: Would not desire LST when facing incurable illness & suffering great pain • Heard of living will? • 1990: 71% • 2005: 95% • Have a living will? • 1990: 12% • 1997: 28% (Gallup Institute) • 2005: 29% • Pew Research Center, 2006

  13. Can We Do Better? • Too few prepare advance directives • Personal goals & preferences can change over time • Preferences may be ambiguous • Surrogates may not understand wishes • Providers may not know about directives • Provider may not follow directives • Fagerlin & Schneider (2004). “Enough: The Failure of the Living Will,” Hastings Center Report, 34, 30-42.

  14. COMMUNICATIONS APPROACH • Issue: Modify formal process with ongoing communication • More flexible approach helpful • Promotes thoughtful discussions with family & providers about values & preferences for care

  15. COMMUNICATIONS APPROACH • Public outreach campaigns • Last Acts • Community-State Partnerships for End-of-Life Care • Caring Conversations Workbook (Center for Practical Bioethics) • www.practicalbioethics.org

  16. COMMUNICATIONS APPROACH • Five Wishes: Aging With Dignity • Personal, user-friendly, non-legalistic document • Incorporates planning concepts • Valid in 40 states • www.agingwithdignity.org

  17. INNOVATION: PHYSICIAN ORDERS • Physician Orders for Life-Sustaining Care (POLST): Oregon, 1991 • www.ohsu.edu/polst • Patient preferences for LSMTs & comfort care become part of medical chart • Encourages discussions among providers, patients & families

  18. INNOVATION: PHYSICIAN ORDERS • Here & now tool, not for advance care planning • Best for advanced chronic progressive illness & those likely to die within year • Transfers among care settings • Integrates into electronic medical records • Endorsed programs in 7 states; many others developing programs

  19. FUTURE STEPS • Continued value for formal advance directives • Communications approaches significant developments • Medical orders provide practical process

  20. FUTURE STEPS • Electronic medical records present opportunities • User-friendly, simple, non-legalistic approaches helpful • Importance of communication creates opportunities for social workers, regardless of approach

  21. For more information call:Gary L. Stein, JD, MSW Associate Professor Wurzweiler School of Social Work Yeshiva University 2495 Amsterdam Avenue New York, NY 10033 212-960-5400, ext. 5442 glstein@yu.edu

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