Improving Patient-Physician Communication about End-of-Life Care: Virginia POST

The Virginia POST Collaborative

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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

But my patient has a living will and a medical power

of attorney---isn’t that enough?

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.

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.

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

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 ?

Conversations that change over time

Source: Carol Wilson, Riverside Health System; Used with permission

Healthy Adults: Emergency Planning

People with Progressive Illness: guided planning

End Stage Illness: Physician Orders for Scope of Treatment

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

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

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

Living Will* Compared to POST

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

*Fagerlin & Schneider. Enough: The Failure of the Living Will.Hastings Center Report 2004;34:30-42.

Century of Change*1900 2008

Average age of death 47 years of age 78 years of age

Causes of death Infection 34% Heart Disease 25%

Heart Disease 9% Cancer 23% CVA 7% COPD 6%

Accidents 5% CVA 5%

Time of disability before death

Days, weeks 2 Years average

*2008 CDC statistics

Chronic Disease with Exacerbations

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”

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

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

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

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

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

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

Progress of the POLST Paradigm

POLST is expanding http://www.ohsu.edu/polst/

Regional POST Projects

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 hospicesClinical and administrative

representation from each organization

Worked to develop a commonly acceptable POST form

Virginia POST Pilot Regions

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 ?

ACP Facilitator Training

Respecting Choices curriculum:http://respectingchoices.org/

Fundraising from regional funding sources for training process.

12 training sessions with nearly 400 facilitators trained from multiple disciplines

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

QI Results of Roanoke Pilot Project

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: Most forms filled out correctly POST orders followed as written in almost all

cases Problem areas addressed

Patient/Family Satisfaction Surveys: Almost all rate the ACP session favorably

Transfer and Place of DeathDecember 2009-May 2011

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 the hospital

Residents who died without POST form: 25 % died in hospital

Implications to hospitals/facilities for readmission scrutiny

Moving POST into Other Areas of Virginia

Virginia POST Collaborative Executive Committee Statewide Advisory Committee

Groups/organizations in 3 additional regions are planning/conducting POST Pilot Projects over the next 2 years

Goal: Work with stakeholders and lawmakers to: Make POST the standard practice Provides consistency, portability as well

immunity to those signing a POST form and those who carry out the orders on the form

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

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 Charlottesville Pilot