Are You “POST- ing ” Yet?

1. Are You “POST-ing” Yet? Christopher W Pile, MD Laura Pole, RN, MSN Tanya Scott, BSW Peter Mellette, Esq

2. We wish to acknowledge support from: The Geriatric Training and Education (GTE) funds appropriated by the General Assembly of Virginia and administered by the Virginia Center on Aging at Virginia Commonwealth University.

3. Objectives • Describe the need for a system to ensure respect for patients’ preferences at the end of life • Review the National POLST Paradigm • Review the current regional POST Projects

4. But my patient has a living will and a medical power of attorney---isn’t that enough?

5. An Index Case Mr. Jan, a 71-year-old male with severe COPD and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing SOB and decreasing LOC over 24 hours. The nursing facility staff called EMS who found the patient unresponsive, with a RR of 8 and an O2 sat 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.

6. After EMS was unable to intubate him at the scene, they inserted an oral airway, bagged, and transported the patient to the emergency department (2nd hospital). Mr. Jan remained unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P of 105 , RR of 8, and an O2 sat 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.

7. What went wrong?(Could this happen in Virginia?) • 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

8. Living Wills Have Been Inadequate in Affecting Care at the Bedside • 25% of healthy adults have ADs • 50% of people with advanced illness • Completed without guidance • Not applicable until patients are “terminal” • Focused on a menu of choices rather than desired (and reasonable) outcomes • In one study, families accurately stated what was important to their loved one who had a terminal illness only 50% of the time.* • Depression and Impact of Event scores were significantly lower for bereaved families when they had participated in Advance Care Planning.** *Engleberg, R., Patrick, D . & Curtis, J.R. (2005) ** Journal of Pain & Symptom Management March 2007

9. Let me ask again . . . In the case of a person with a terminal or serious progressive illness, is having a living will and durable medical power of attorney enough ?

10. Conversations that change over timeSource: Carol Wilson, Riverside Health System; Used with permission

11. Healthy Adults • Name a Healthcare Agent • Prepare for sudden injury or event • Complete basic Advance Directive Source: Carol Wilson, Riverside Health System; Used with permission

12. Progressive Illness • Understand potential complications and treatment options • Consider benefits and burdens of end of life treatments • Discuss preferences with family • Make Advance Directive more specific • Re-evaluate goals with changes in condition Source: Carol Wilson, Riverside Health System; Used with permission

13. Late Stage Illness • No longer hypothetical • Express preferences for treatment as medical orders • Use POST form in communities where it is accepted Source: Carol Wilson, Riverside Health System; Used with permission

14. For every adult Requires decisions about myriad of future treatments Requires interpretation Needs to be retrieved For the seriously ill Decisions among presented options Medical orders which turn a patient’s values into action Follows patient across settings of care on consistent document Living Will* Compared to POST *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42.

16. Century of Change* *2008 CDC statistics

17. Chronic Disease with Exacerbations

18. Evolving Realities • Increased prevalence of chronic disease • Increased comorbidities and frailty with medical advances adding to complexity • People receive care: They do not want From which they cannot benefit • People fail to receive care: They do want From which they will benefit • Death is “optional”

21. Key to Effective Conversations Bud Hammes, PhD., 2009 Presentation: Respecting Choices®, an Advance Care Planning System that Works. • Listen to the patients’ or patients’ representatives’ perspective • Identify gaps, fears, and other barriers to decision-making • Explore personal goals and values regarding remaining life • Consider what medical care will or will not help achieve these goals within acceptable burdens of treatments 21

22. Resources for The Conversation • The Conversation Project • www.theconversationproject.org • Respecting Choices • www.respectingchoices.org

23. What is POST? • A physician order • Can be completed by any provider but must be signed by qualified MD or DO • Complements, but does not replace, advance directives • Voluntary use

24. POST is designed to honor the freedom of persons with advanced illness or frailty to have or to limit treatment across settings of care • POST is Entirely Voluntary: • No one has to complete a POST • Choice to have or limit treatments • Revoke or change at any time • Comfort measures are always provided

25. Purpose of POST • To provide a mechanism to communicate patients’ preferences for end-of-life treatment across treatment settings • To improve implementation of advance care planning • Ensure care delivered reflects patient’s preferences, values, and goals

26. POST is for… Seriously ill patients* Terminally ill patients * chronic, progressive disease/s

27. Why POST Works • Transfers across care settings • Contains specifics • It IS a physician’s order—no interpretation is needed and POST orders are to be followed

28. Components of the POLST Paradigm • Standardized practices and policies • Trained advance care planning facilitators • Timely discussions prompted by prognosis • Clear, specific language on an actionable form • Bright form easily found among paperwork • Orders honored throughout the system • QI activities for continual refinement

29. A System-wide Approach • Different settings • Nursing Home • Home • EMS • Hospital • Uniform response • Document that indicates specific responses to various likely complications • Avoidance of “getting it wrong” • Failure of planned action to be completed as intended

30. AMDA Weighs In • “We welcome additional data and new models of care that will help us create and evolve optimal processes for transitions between care settings.” • “ In the meantime, we propose some basic tenets that we believe, at least intuitively, will serve as underpinnings to enhance safe and efficient transitions . . .

31. AMDA Supports the POST Process • Consistent discussion and documentation of advance directives and end-of-life care preferences, with up-to-date PO(L)ST forms or, in states where these are not available, with other appropriately executed advance directive forms.

32. National POLST Paradigm Programs Endorsed Programs Developing Programs *As of February 2013 No Program (Contacts)

36. Regional POST Projects

37. Regional POST/ACP ProjectRoanoke Valley Initiative of Palliative Care Partnership of Roanoke Valley: http://www.pcprv.org One hospital, two skilled nursing facilities, and three hospices Clinical and administrative representation from each organization Worked to develop a commonly acceptable POST form

39. Is the Document Enough? The POLST form is an essential element of a system to document and transmit patient care preferences, but it is not the MAIN thing. Careful discussions that elicit care preferences ARE the main thing. Who will facilitate these discussions ?

40. Respecting Choices® POST ACPFTraining • Designated ACPF training model for Virginia • Fundraising from state and regional funding sources (including GTE) for training process. • Pre-workshop online learning modules + all-day workshop. • 15 training sessions with nearly 450 facilitators trained from multiple disciplines

41. End-User Training • Inservice training for health professionals who come into contact with POST form: EMS, ED and other specific hospital units, hospice, nursing care facilities. • Conducted organizational specific inservices before “go live” • Thousands of end-users training in pilot regions

42. Training for PCP’s • Problem: Few physicians have time to participate in RC Training • GTE Grant: Develop, pilot and refine a one-hour training for physicians caring for POST-appropriate patients. • Theme: Promote It, Sign It, Honor It • Presentations began May 2013; plan to offer in pilot project regions in the upcoming year. • CME credits granted

43. Roanoke Pilot Project QI • Began in December 2009 • Most ACP discussions and POST forms were done in nursing care facilities • QI data collected from medical records of nearly 100 residents/patients with POST forms: • 98% congruency between orders written and care delivered

44. Transfer and Place of Death • 9 transfers • 1 to ALF • 4 to ED (2 for foley insertion, 1 for GI bleed; other unknown) • 2 admitted to hospital (1 died in hospital, other returned to facility) • 2 transferred to VAMC Palliative Care unit. • Place of Death: Only 1 patient with a POST form died in an acute care unit in the hospital • Residents who died without POST form: 25 % died in acute care setting in hospital • Implications to hospitals/facilities for readmission scrutiny

45. Bringing POST to your facility • Are you in a POST Pilot Project Region? • No: Contact Laura Pole about what’s involved in getting a pilot project going • Yes: Contact your region’s POST Coalition Coordinator (see list on last 2 slides) • Agreeing to standards for site implementation. • On-site POST coordinator/point person; rep. to regional POST coalition • Trained POST Advance Care Planning Facilitators • Time allocation for facilitators to do Advance Care Planning • End-user trainings • Education/outreach to medical directors and PCP’s • Policies and procedures • Follow-up QI

46. Bottom Line • POLST Paradigm is achieving its goal of honoring tx preferences of those with advanced illness or frailty. • Plus----”POLST/POST serves as catalyst for conversations in which pts. talk with their loved ones and their health care professionals about what they really want” • Alvin Moss, MD; Medical Dir. Of Center for Health Ethics and Law of WV University

47. Participating in POSTIn TheNursing Home Tanya Scott, BSW

49. What Is The Next Step? • Decide to participate in POST • Who are key players in facilities? • Who can be champions for POST?

50. Take-Home Messages • POST provides a better means than AD alone to identify and respect patients’ wishes • POST completion will improve end-of-life care throughout the system • Use of POST will require communication to make it work in your community • Consider joining the Virginia POST Collaborative Statewide Advisory Committee • Consider participating in a Regional POST Project