POST: A Better Way to Communicate Patients’ End

of Life Care WishesLaura Pole, RN, MSN, OCNSVirginia POST Collaborative

“Death is an inevitable aspect of the human condition.

Dying badly is not.”

Jennings, et al, 2003

Need for more specific advance care planning at the end of life.

The process of making POST available in Virginia as a communication tool for end of life care wishes.

How POST is affecting end of life care at the bedside.

Resources

We will explore:

But my patient has a living will and a medical power of

attorney---isn’t that enough?

An Index Case

Mr. Jan

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

What went wrong?(Could this happen in your area?)

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 ?

Let me ask again . . .

Healthy Adults: Emergency Planning

People with Progressive Illness: guided planning

End Stage Illness: Physician Orders for Scope of Treatment

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

Name a Healthcare Agent

Prepare for sudden injury or event

Complete basic Advance Directive

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

Healthy Adults

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

Progressive 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

Late Stage Illness

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.

No specific end of life care orders means patients want full interventions. ◦ Maybe, maybe not . . . ◦ And what’s the default if the patient can’t tell

you? A DNR order means a patient doesn’t want

more than comfort measures.

When there is no POST form—dangerous assumptions

DNR Status is not a predictor of the care patients wish for at the end of life—many with DNR chose limited or full interventions as well as artificial nutrition.

PO(L)ST is a neutral form—allows patients to have or limit treatment.

PO(L)ST reduces making assumptions based on DNR status alone.

Study: DNR Orders and Other End of Life Care Treatment Preferences

Fromme, E.K. Zive, D., Schmidt, T.A., Olszewski, E. & Tolle, S.W. (2012). POLST Registry, Do-Not-Resuscitate orders and other patient treatment preferences. Journal of the American Medical Association, 307(1), 34-35.

Evolution of POST in Virginia

2007 2008 2009 2010 2011 2012 2013

History of POST in Virginia

IDEA +1 Local Pilot Project State Stakeholders

Grant & In-Kind Support

+ =

Virginia POST Collaborative

&13 Regional

POST Programs

The POST Form

POST Pilot Regions in Virginia

It’s Not Just About the Form—It’s Mostly About the Conversation.

Being Clear with the Message

Clear Message: Who is appropriate for POST?

Becoming a participating pilot project region.

Advance Care Planning Facilitator Training PCP Training End-User Training Public Education

Education

POST is for:Seriously ill patients*Terminally ill patientsThose with advanced frailty

Gives options to limit or have care

VoluntaryCan be revoked or changedComfort measures always offered

Messaging:

* chronic, progressive disease/s

◦Ongoing training, mentoring and support

◦POST Pilot Project Training Webpage

◦Training webinars and presentations

◦One-on-one consultation

Training Regional Pilot Project Groups

Careful discussions that elicit care preferences ARE the main thing.

Who will facilitate these discussions ?◦ Non-physician POST ACPF’s must be certified in

order to have conversation and assist in POST form completion

Advance Care Planning Facilitator Training

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

Respecting Choices® POST ACPFTraining

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 scheduled for May and June

2013 CME credits granted Future: Conduct train the trainer so that

regional pilots can host these trainings.

Training for PCP’s

For care providers who are likely to come in contact with a patient with a POST form.

Participating hospitals, nursing care facilities, hospices, EMS, and other care settings.

GTE Funding to refine template presentations in multiple formats:◦ Live presentations◦ Online self-paced module

Thousands of end-users trained in pilot regions.

End-User Trainings

Primarily limited to pilot project regions. Growing interest and multiple requests from

patients/families Virginia POST Website:

◦ Funding from National POLST, GTE and a hospital system.

◦ Full website up and running by Summer 2013

Public Education

There’s more work to do . . .

Skilled Trained Facilitators

Laws, Statutes, Regulations

Uniform Policies, Procedures, Standards

POST Form

Can Care Settings Provide

Competent, Compassionate Palliative Care?

Collaborative

Stakeholders and

Coalitions

Resources

Webpage and Communication Plan

Physician Support

Advocacy Plan

Roanoke Valley Pilot Project QI Study

Is Virginia POST Impacting End of Life Care at the

Bedside?

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

Roanoke Pilot Project QI

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

Transfer and Place of Death

An Illustrative Case—Mrs. West

PO(L)ST is achieving its goal of honoring tx preferences of those with advanced illness or frailty.

Plus----PO(L)ST serves as an ACP conversation catalyst”

Bottom Line . . .

Review:◦ Where POST is in Virginia◦ Contacting your Region’s POST Pilot Project

Coordinator No Pilot in Your Area?

◦ Contact Laura Pole (Lpchef@earthlink.net) for guidelines on implementing POST in your community

Bringing POST to Your Area

National POLST Paradigm: www.polst.org

Virginia POST Collaborative: www.virginiapost.org

• National Hospice Foundation: www.hospiceinfo.org

• National Hospice and Palliative Care Organization: www.nhpco.org

• Palliative Care Partnership of the Roanoke Valley: www.pcprv.org

• “Hard Choices for Loving People” by Hank Dunn

Using your resources:

National POLST Paradigm: www.polst.org VHHA:

http://www.vhha.com/healthcaredecisionmaking.html

NHPCO: Caring Connections: http://www.caringinfo.org

National Health Care Decisions Day: http://www.nhdd.org/

Resources for Advance Care Planning

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 requires communication to make it work in your community

Local, Regional and Statewide collaboration is pivotal to making POST available as a uniform, portable and legal document and process.

In Conclusion:

Questions?

We could make it holy.

Because you made it normal . . .