CCRMC Introduction to POLST

1. CCRMC Introduction to POLST Ray Jarvis VITAS Forrest Beaty MD

2. If you are dying in Miami, the last 6 months of your life might well look like… • You’ll see a physician, mostly specialists 46X • Spend more than six days in ICU • Stand a 27% chance of dying in the hospital • The bill for physician / hospital care will be > $23,000 Medicare Analysis Dartmouth Medical School

3. If you are dying in Portland, OR, the last 6 months of your life might well look like… • You’ll visit your doctor 18 times • 50% of those visits will be with your PCP • One day in the ICU • 13% chance of dying in the hospital • More likely to die at home on hospice • Bill for hospital / physician care $14,000

4. End of life facts • 27% of Medicare’s annual $327 billion budget goes to care for patients in their final year of life. • > 80% of respondents said they would like to die at home, surrounded by family and friends. • Approximately 70% of Americans die in health care facilities (55% hospital, 16% in LTC)

5. How can we reduce the mismatch between patient wishes and reality? • What can we do to ensure patient’s end of life care wishes are honored?

6. What is POLST? Physician Orders for Life Sustaining Treatment

7. Why POLST? • Patient wishes often are not known. The Advance Health Care Directive (AHCD) may not be accessible, clear, or honored. • Allows healthcare professionals to know wishes for end-of-life care and honor them.

8. Case Study: What We Know • Mr. Jones, an 83 year old man with severe chronic obstructive pulmonary disease (COPD) and mild dementia. • In skilled nursing facility (SNF) after hospital stay for pneumonia. • Developed increased shortness of breath and decreased responsiveness. • SNF called Emergency Medical System who transported patient to hospital.

9. Case Study: What We Know • Emergency Room physician could not find any code status information in SNF papers. • Wrote “Full Code for now, status unclear.” • Mr. Jones was intubated and transferred to the ICU.

10. Case Study: What We Didn’t Know • Mr. Jones had an AHCD. It was at his home so the SNF couldn’t send it to the hospital. • Mr. Jones had talked with his family and SNF staff about his desire not to go back to the hospital and receive aggressive treatment. • There was no documentation of the conversation to alert the ED staff. • The weekend nurses at the SNF could not reach his family and did not know about his wishes.

11. Case Study: What Went Wrong • AHCD not transferred with patient. • DNR wishes not documented. • Over-treatment against patient wishes. • Unnecessary pain and suffering. • System-wide failure to document and honor patient wishes.

12. What is POLST? • A physician order recognized throughout the medical system. • Portable document that transfers with the patient. • Provides direction for a range of end-of-life medical treatments. • Brightly colored, standardized form for entire state of CA.

13. Who Needs POLST? • Chronic, progressive illness • Serious health condition • Medically frail • Tool for determination • “You wouldn’t be surprised if this patient died within the next year.”

14. POLST History • POLST development began in Oregon in 1991. • Initially for SNF patients transferred from one care setting to another. • Use of POLST now expanded to more than 23 states. • Oregon study of 180 SNF patients – POLST stated: No CPR and Comfort Measures Only. Patient wishes were honored.

16. POLST in California • California Coalition for Compassionate Care (CCCC) is lead agency with support from California HealthCare Foundation • CA Assembly Bill 3000 • Effective January 1, 2009 • One form for entire state • Use not mandated • Honoring form is mandated

17. Does POLST Replace the Advance Health Care Directive? • POLST does not replace the Advance Health Care Directive (AHCD). • AHCD allows you to name a health care decisionmaker if in the future you are unable to communicate wishes. • Encourage everyone 18 years and older to complete an AHCD.

18. Where Does POLST Fit In? Advance Care Planning Continuum Age 18 Complete an Advance Directive C O N V E R S A T I O N Update Advance Directive Periodically Diagnosed with Serious or Chronic, Progressive Illness (at any age) Complete a POLST Form End-of-Life Wishes Honored

19. POLST vs. Pre-Hospital DNR(Do Not Resuscitate) • POLST and Pre-Hospital DNR: • Physician orders • Address Do Not Resuscitate • Medically frail or those with chronic or serious illness • POLST: • Allows for choosing resuscitation • Other life-sustaining treatments • Honored across all healthcare settings • Pre-Hospital DNR: • Honored outside hospital only (home, assisted living, SNF, EMS system)

20. POLST vs. PIC(Preferred Intensity of Care) • Both include choices for medical interventions • PIC forms are not medical orders and do not transfer to other settings • POLST can replace the PIC form at SNF

24. Section B: Medical Interventions CPR DNR Comfort Measures Limited Treatment Full Treatment* *Consider time/prognosis factors under “Full Treatment” “Not to be kept on life support if not expected to recover.”

30. Who Can Speak for the Patient • Agent/surrogate decisionmaker • Parent, guardian, conservator • Closest available relative

31. When to Review POLST • Patient’s treatment preferences change. • Change in patient’s health condition. • Transfer from one care setting to another. • Patient Care Conference.

32. Can POLST be Changed? • Individual with capacity can change the POLST at any time. • A health care decisionmaker may request a change to POLST based on a condition change or new information regarding patient wishes if patient lacks capacity. • If care is medically ineffective or contrary to accepted health care standards.

33. POLST: Depth of the Process • POLST is not just a form. • POLST facilitates rich conversations which integrate patients’ values and preferred preferences for treatment. • POLST is not an Advance Directive, but part of POLST completion is encouraging completion of an AHCD. • POLST incorporates the depth of comfort care which applies to everyone.

34. California POLST Project The California Coalition for Compassionate Care (CCCC) provides leadership and oversight for POLST outreach activities in California, with support from the California HealthCare Foundation. C alifornia C oalition for C ompassionate C are

35. California POLST Project Translating an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for medical treatment. POLSTConversation A rich conversation with each individual patient Community Collaboration Integrating POLST into the community standard of care Consistent Form Standardized form recognized across care settings Comprehensive Education To promote excellent conversational skills with patients and families

36. California POLST Form • Available at www.capolst.org • Print on pulsar pink, 65# card stock paper • Copies are acceptable • Focus on the conversation

37. POLST Resources • Provider and consumer brochures • Frequently Asked Questions (FAQs) • Guidebook for healthcare professionals • Model policies and procedures • Standardized educational curriculum • Local POLST coalitions • www.capolst.org

38. Model Policy for Skilled Nursing Facilities • The purpose of this policy is to define a process for skilled nursing facilities to follow when a resident is admitted with a Physician Orders for Life Sustaining Treatment (POLST). • This policy also outlines procedures regarding the completion of a POLST form by a resident and the steps necessary when reviewing or revising a POLST form.

39. Other Resources • Questions you might want to ask • Facilitating Care Conferences and Family Meetings • POLST Cue Card • “I Love You Mom” conversation guide www finalchoices.org

40. Where Do We Go From Here? • Dr Beaty’s clinical perspective • Train SW, RNs and case managers to have the “conversation” • Implement in your facility • Train personnel to be POLST proactive