Actionable Advance Directives

1. Actionable Advance Directives Stephen Telatnik,M.D. Hope for the Future: Achieving the Original Intent of Advance Directives

2. GOALS • Review the reasons why advance directives have not achieved the status expected in the last 20 years. • Explore possible improvements and examples. • Concentrate on actionable medical directives especially POLST. • Review progress in El Paso County and Colorado towards actionable medical directives.

3. What are actionable medical directives? • Physician medical orders regarding end of life issues • Do not replace traditional medical directives. • Help to define in a timely manner patients wishes in specific areas. • Need to transfer across care settings.

4. Statutory Advance Directives • Only 20 to 30 percent of American adults have advance directives. • Limited effect on end of life treatment

5. Reasons for Failure • Focus on legal rights to refuse treatment without understanding the persons goals and values. • Instructions are either too vague or too specific to lead to constructive conversations and decision making. • No timely follow-up after initial form completed • Not integrated into clinical care planning

6. Reasons for Failure (cont.) • Autonomy is assumed to be the primary mode of decision making. • Insufficient instructions are included for surrogates and/or physician. • Intention of patient to allow surrogate to make decisions is not addressed.

7. Elements of Successful AD Programs • Individualized plan must include person’s values, goals, medical condition,and culture. • Actionable AD involves physician orders for current treatment preferences across care settings utilizing a standardized highly visible form. . • Staged timing: revisit AD with changing prognosis • Increasing chronic disease and frailty necessitate review of goals frequently.

8. Elements (cont.) • Policies, procedures and teamwork within each part of the healthcare system are necessary. • QA initiatives to ensure each element of the system is achieving desired outcome. • States end of life coalitions of key stakeholders is essential to ensure portability.

9. New Models • “Five Wishes” • “Let Me Decide” • “Respecting Choices” • POLST

10. FIVE WISHES • Incorporates surrogate appointment with range of wishes: medical, personal, spiritual and emotional needs. • Meets legal requirements in 37 states including Colorado and District of Columbia. • No published studies to support efficacy.

11. LET ME DECIDE • Program in Ontario, Canada nursing homes and hospitals to document health care choices in several areas. • Staff training on how to integrate AD into care. • Documented increase level of planning and decreased deaths in hospitals.

12. RESPECTING CHOICES • Community-wide care planning system in La Crosse, WI • Training and defined role for HCP in advance planning • 85% of all decedents had written AD • Medical decisions near time of death were consistent with written instructions 98% of the time.

13. Physician Orders for Life Sustaining Treatment • Order form that converts patient treatment preferences into written medical orders primarily in nursing homes • Form transfers with patient across care settings • Used in thirteen states • “Respecting Choices” recommends POLST

14. POLST • Brightly colored, clearly identifiable form • Orders that address a range of life-sustaining interventions. • Portability across treatment settings requires acceptance and understanding of EMS, ER, and hospital personnel.

16. Case Study • 73 y/o male with total knee replacement admitted to nursing facility for rehab. • On admission, physician reviews with patient and signs POLST. • Wishes to be resuscitated, receive full treatment, antibiotics and tube feeding. • He develops PE, transferred to the hospital and receives full treatment.

17. FAQ’S • Who should have the original form? • Should be with patient at all times • Does the POLST require pt. signature? • It is not an AD, which does require it. • What if patient has an AD? • AD will provide information to complete POLST form

18. FAQ’S • Can the POLST be used to guide daily care? • Yes, it provides information regarding transfer to hospital and about feeding tube insertion. • Does a physician need to fill out form? • No, can be done by nurse or social worker. • Can the form be filled out without a conversation with the patient or surrogate? • No, it must also document who was asked.

19. History of POLST • A state wide effort in Oregon coordinated by OHSU Department of Ethics • Task force organized in 1991 and POLST form finalized in 1995. • Project was in place three years before the Death with Dignity Act passed. • Ongoing research contributes to improvements in POLST.

20. POLST research • Numerous studies published in peer-reviewed journals documenting efficacy • Hickman et al JAGS 32:1424-1429 2004 • 2002 – 71% of Oregon nursing homes using POLST for at least 50% of patients • Records audited at 7 facilities: 88% completed • DNR pts: 54% chose other limitations • Non DNR pts: 47% chose some limitation

21. The National POLST Paradigm Initiative • Promotes the concepts of POLST across the country • Supports coalition building and statewide collaboration. • Provides educational material for healthcare professionals and lay public. • Supports ongoing research about POLST and end of life issues.

22. The National POLST Paradigm Initiative • Programs based on the POLST paradigm are now used in Washington and West Virginia and parts of Wisconsin, Pennslyvania, New York, Utah, New Mexico, Michigan, Georgia, and Minnesota. • Currently, there is a dialog with NPPI here in Colorado; however, we have not met guidelines to be formally included.

23. Actionable Advance Directives in Colorado • Colorado Advance Directives Consortium organized August 18, 2006. The steering committee: • Denver Regional Council of Governments • Task force on EOL, State Bar Association • Colorado Dept. of Health, EMS Division • Colorado Medical Director Assn. (LTC) • Colorado Med. Society/El Paso County Med. Society • Hospice Physicians

24. Colorado Advance Directives Consortium • Convened a meeting of interested parties on September 29, 2006 in Denver • Topics discussed: • Living will law and legislation • Portability of advance directives • Proxy and surrogate decision-maker • CPR Directive issues

25. Colorado Advance Directives Consortium • Since the general meeting in August 2006, the steering committee has investigated the issue of portability extensively. • After a teleconference with a Dr. Dunn of the National POLST Paradigm Initiative, the Consortium has decided to explore the possibility of using POLST in Colorado

26. Colorado Advance Directives Consortium • The Consortium is supporting pilot projects in EL Paso County as well as Denver. • The Centura system as well as Evercare has already began projects.

27. El Paso County • El Paso County Medical Society • Ethics Committee/Probate Section Bar Assn: • Regularly monitors and promotes POLST activity • Extended Care Ethics Committee • Oversees POLST activities in nursing homes • Meeting is being planned with EMS, ER, and hospitals • Penrose Hospital is introducing POLST for inpatients is discussions with Memorial Health Systems.

28. Southern Colorado • Under the direction of Dr. Feinsod, nursing homes, EMS, and local hospitals in three communities have initiated POLST discussions.

29. In Conclusion • Reviewing the history of advance directives has led to innovative ways of protecting the wishes of individuals approaching the end of life. • Physician orders for life-sustaining treatment across all care settings appears to be the most reasonable way to achieve this goal.