Advance Care Planning

1. Advance Care Planning Presented by Janice L. Benson, MD Vice Chair of Education Work of Maurice Scott, MDResearch Fellow , Palliative Medicine

2. Objectives • To recognize the importance of Advance Care Planning (ACP) for patients and their families. • To understand the role of the physician in the ACP discussion. • To appreciate where physicians can improve their communication styles to optimally facilitate an ACP discussion.

3. “We recommend that communication about end-of-life treatment decisions be treated as a medical skill to be taught with the same rigor as other clinical procedures.” JGIM; 1995, Tulsky et al.

4. The Question How well are medical students trained at discussing advance directives with their patients?

5. Does this represent you? • OK, Mrs. Jones, there is just one other thing I need to ask you about your Mom, and that’s about what you would want us to do if her heart were to stop or she needed to be on a breathing machine. Would you want us to pound on her chest and use electrical shocks if her heart happens to stop? If she stops breathing, would you like us to put a tube down her throat?

6. Medical Student Training in End-of-Life (EoL) Communication • Ury et al., 2003. • Self-Administered Questionnaire to incoming interns • Assessed medical school training in end-of-life communication • Results: • 157 completed surveys • Very little classroom teaching or clinical observation/experience • Lacked comfort and skill in end-of-life communication

7. Understanding the EoL language • Do and Ogrinc, 2011 • Survey given to medical students at end of internal medicine clerkship. • Assessed understanding, knowledge, experiences, and attitudes toward code status • Results: • “On the job training” was primary means of knowledge of code status • 100% knew what “code status” meant; only 17% reported an “excellent” understanding • Only ~ 5% of student were “extremely comfortable” in facilitating a code status conversation

8. How well do residents talk about CPR? • JGIM; 1995, Tulsky et al. (n=45) • Nature of the Procedure • Mech. Ventilation 100% • Endotracheal Intubation 84% • Cardioversion 68% • Chest Compressions 55% • Intensive Care 32% • Outcomes • Any Likelihood of Survival with CPR 13% • Numerical Estimate of Survival O% • Patient’s Values or Goals 10%

9. How well do residents talk about CPR? • JGIM; 1995, Tulsky et al. • Risks • Prolonged ICU Stay 3% • Neurologic Sequelae 13% • Procedure-Related 16% Complications • Alternatives • Death 6% • Comfort Measures 32%

10. How well do residents talk about CPR? • JGIM; 1995, Tulsky et al. • Not Enough Info for Informed Choices • Probabilities / Any Quantitation • Little Attempt at Eliciting patients Values / Goals / Concerns • Physician Dominated Discussions • Average Time = 10.5 minutes (2.5--36.1) • Patients Spoke Avg = 2 mins 36 secs • Residents Perceptions • 90% Self-Assessed “Good Job” • 77% Reported being “Comfortable” • 33% Reported having Never been Observed • 71% Observed 2 or Fewer Times

11. CPR Statistics • Taffet, et al. retrospectively studied 399 CPR efforts in 329 patients from 1984-1985 at the Houston VAMC • 327 patients were men, age ranged 25-93, mean 62.6 years • Older vs. younger cohort • 24/77 (31%) successful CPR efforts in patients 70 or over, but none survived to discharge • 137/322 (43%) successful CPR efforts in patients younger than 70, and 22 (16%) survived to discharge • mental function was more impaired in the older cohort after the arrest • Poor predictive factors • diagnosis of cancer - 33/89 (37%) patients successfully resuscitated and none survived to discharge • diagnosis of sepsis - 33/73 patients resuscitated and one survived to discharge • age was a poor predictive factor, even when controlling for severity of illness, except cancer and sepsis

12. Discussing and Documenting Advance Directives • THE IDEAL WORLD • Should happen with everyone • The discussion should be an evolving one • Exploring the patient’s values (i.e. what makes life worth living) • Matching available medical practices with the patient’s values • Allot as much time as needed for the conversation…should not be done in a rush. • THE WARD WORLD • Done in the ED on admission • The very sick and very old • Oftentimes conversation lasts no more than a few moments • Performed by a provider who just met the patient • Often in time-pressured setting and done on the fly

13. Discussing and documenting Advance Directives 1. Are there advance directives/living wills in place? 2. Do you think CPR is appropriate? 3. Is patient decisional? •Is there a guardian? •Is there a named surrogate and documentation? 4. Know who patient wants to participate 5. Do other team members want to participate?

14. ACP Over Time • Advance Care Planning Over Time • FIRST STEPS: Complete a PoA. Think about wishes if faced with severe trauma and/or neurological injury. • NEXT STEPS: Consider if, or how, goals of care would change if interventions resulted in bad outcomes or severe complications. • LAST STEPS: End-of-Life planning - establish a specific plan of care using POLST to guide emergency medical orders based on goals. Maintain and Maximize Health, Choices, and Independence

15. HCPOA • State dependent • Recommended for all decisional adults, regardless of their current health status • HCPOA only has “power” when the patient is deemed not decisional • So when would a patient be deemed to lack decision-making capacity??

16. Surrogate Act of IL • Instituted when patients lack decision-making capacity who have not appointed a HCPOA. • Order of hierarchy  Guardian, spouse, adult son/daughter, mom/dad of the patient, adult siblings, adult grandchildren, close friend of the patient, guardian of the estate

17. POLST Also known as the “new” DNR form

18. Vignette #1 Mr. James • 60 yo male PMH metastatic prostate cancer • Independent in ADLs • During discussion, it is clear that he recognizes that his illness is terminal and does not wish to undergo CPR or intubation • Is willing to attempt low-burden, less-invasive measures to prolong his life • How should POLST be filled out?

19. Vignette #1 Cont. Months later, he is admitted to hospital with hypotension 2/2 urosepsis. * According to his POLST, what life-sustaining treatments can be used? * Should/could he be transferred to ICU?

20. Vignette #1 Cont. • During prior hospitalization, decision was made to enroll patient in hospice and POLST form is changed to reflect this change in his goals of care. • One day, while eating lunch at home, he chokes on a hot dog while the hospice nurse is present  unable to cough, talk, or breath • Is performing the Heimlich in accordance with his wishes for comfort measures alone?

21. ACP Over Time • Advance Care Planning Over Time • FIRST STEPS: Complete a PoA. Think about wishes if faced with severe trauma and/or neurological injury. • NEXT STEPS: Consider if, or how, goals of care would change if interventions resulted in bad outcomes or severe complications. • LAST STEPS: End-of-Life planning - establish a specific plan of care using POLST to guide emergency medical orders based on goals. Maintain and Maximize Health, Choices, and Independence