The NC MOST Project Collaboration in Action

1. The NC MOST ProjectCollaboration in Action Susan Redding, MSN, APRN-C NCNA NP Spring Symposium April 20, 2008

2. MOST….MedicalOrders for Scope of Treatment Respecting Patients’ Wishes for care at the End of Life

3. An Index Case Mr. Jan (a pseudonym), a 71-year-old man with severe chronic obstructive pulmonary disease and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing shortness of breath and decreasing responsiveness over 24 hours. The nursing facility staff called the emergency medical service, who found the patient unresponsive, with a respiratory rate of 8 breaths/min and oxygen saturation 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.

4. After the emergency team was unable to intubate him at the scene, they inserted a nasal pharyngeal airway, administered supplemental oxygen, and transported the patient to the emergency department of a second hospital. Mr. Jan remained unresponsive. He was afebrile, with a systolic blood pressure of 190 mm Hg, a pulse of 105 beats/min, a respiratory rate of 8 breaths/min, and an oxygen saturation 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.

5. What went wrong? – Could this happen in your community? • 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 of care

6. Why not rely on the Advance Directive??? • AD may not be available when needed • AD may not have prompted needed discussion and may not be specific enough • No provision for some specific treatments • May not cover topics of most immediate need, i.e., site of care • May not be provider agreement that AD should be effected – “is this person terminal??” • AD does not immediately translate into a medical order

7. Advance Care Planning circa 2008 • Identification of Medical Power of Attorney • Goals of treatment • Cardiopulmonary resuscitation (CPR) • Feeding tubes • Mechanical ventilation • Dialysis • Organ and Tissue Donation • Preferred site of death and those present at death

8. Purpose of MOST • To provide a mechanism to communicate patients’ preferences for end-of-life treatment across treatment settings • To improve implementation of advance care planning

9. Why MOST Works • By law MUST accompany patient • Contains specifics • It IS an order—no interpretation is needed • Statute provides safe harbor for providers

10. Who benefits from a MOST? • Persons who have advance chronic progressive illness • Those who might die in the next year “Would you be surprised if this patient died this year?” • Anyone wishing to further define their preferences for healthcare interventions

11. MOST in North Carolina • 2004: North Carolina pilots POST • Mission Hospitals in Asheville • Physicians from Buncombe and Henderson County Medical Societies ask NCMS to study POST • NCMS agrees and assigns to NCMS E & J Affairs Cmte; • Early 2005: NCMS Ethical and Judicial Affairs Committee decides to pursue NC POST form and appoints subcommittee • 2005 POST pilot begins in Pitt Co. • 2006: POST Task Force formed to look at documents • 2006-2007: MOST form modifications; legislation developed and pursued (H 634/Session Law 2007-502) • 2007: NC passed legislation recognizing MOST • 2008: ongoing efforts to develop educational toolkit to • facilitate appropriate utilization of MOST

12. POST Task Force—March 4, 2006 • Physicians • Pilots (Buncombe, Pitt) • Hospitals • Hospice • Home Health • Nursing Homes • DHHS: EMS, DOA, DMA • NCBA (health, elder & estate law) • Nursing • Old North State M.S. NC IOM • NC Med. Dir. Assoc • NC DOJ • Family Policy Council • Life Tree • Catholic Medical Society

13. A Little Bit of History. . . • Began with a journal article describing the work of Dr.Alvin Moss of WVA r/t his development of POST form • Contacted Dr.Moss who facilitated contact with Dr.David Blackmon who was already piloting document in Western NC • Collaborated with NH’s, local geriatrician, geriatric RN/case manager and palliative care team at area hospital

14. More History. . . • Education provided to hospital ED, EMS, case managers, NH staff, some area MD’s and patients/families • In Nov. 2005, began pilot in 3 Eastern NC nursing facilities, utilizing forms/processes already in use in Buncombe Co. pilot

15. Benefits of Collaboration on Pilot • Identified common problem/need r/t honoring patients desires for EOL care • Identified tool with proven track record • Willingness of all players to share expertise, tools, experiences, etc.

16. Benefits of Collaboration Statewide • POST task force attempted to identify all players who might be impacted by form • POST task force sought by-in from all who would be needed to actualize form (regulatory agencies/clinicians/legal counsel/consumers, etc) • Willingness to address ALL expressed concerns and potential problems with form

17. What did we learn?? • Importance of listening to concerns of others • Importance of recognizing that each player comes with needs, with something to offer and with a unique perspective on the project • Importance of keeping the patient’s needs at the center of what we were doing – honoring person’s wishes for care at end of life • That it “takes a village” – and then some. . .

18. What next?? • Develop educational materials • Develop training programs for health care professionals who work with patients and patient representatives to learn to help prepare MOST • Translate materials into Spanish and other languages as needed • Start collecting data on MOST for NC IOM study to be issued in 2013 to assess if MOST has improved EOL care in NC

19. Questions???