CSI-RI Learning Collaborative October 9, 2014
David Gorelick, MD, FACPFull Time Practicing Internist Aquidneck Medical Associates in Newport
since 1995University Medicine Foundation member Jan
1, 2014Lifespan Corporation Board of DirectorsRI HIE (CurrentCare) Advisory Commission
Chairman
No financial disclosures in relation to today’s presentation
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
David Gorelick, MD, FACPAquidneck’s Physician Champion
EMR Super-User – fully electronic since 2005 EMR Training , Maintenance, and Upgrades Patient-Centered Medical Home – 1st in RI NCQA Level 3
in 2009 Practice Transformation – workflow efficiency and staffing
model All Quality and P4P Initiatives – 1st group in RI MU in 2010 CSI-RI beginning Oct, 2013
Newport Hospital Code Committee Chairman since 1995
Newport Hospital Case Management Advisor since 1999
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Today’s DiscussionEnd of life care is an active
interventionWhose wishes are we honoring?
The patient’s? The family’s? The doctor’s?
Patient-CenterednessHaving the discussionLiving Will Durable Power of Attorney for
HealthcareWhere does code status fit in?Comfort OneMOLST
Transitions of Care
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
National Cancer InstituteEnd-of-Life Care for People Who Have Cancer
End-of-life care provides physical, mental, and emotional comfort, as well as social support, to people who are living with and dying of advanced illness.
People who have already discussed their wishes for end-of-life care with their loved ones feel less stress at the end of their life, and so do their families.
Advance directives are legal documents that record a person’s wishes for end-of-life care.
Research has shown that hospice care may improve the quality of life of a cancer patient who is dying and of the patient’s family.
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Hospice CareNational Hospice and Palliative Care Organization
http://www.nhpco.org/Considered the model for quality compassionate
care for people facing a life-limiting illness.Hospice provides expert medical care, pain
management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes.
Support is provided to the patient’s loved ones as well.
Hospice focuses on caring, not curing.
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Case Report – 95y/o with anemiaInterventions vs conservative approach
Patient’s wishes were clearFamily’s agenda differed
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Case Report – 80y/o not recoveringSeizure disorder and IDDM since childhoodAdvanced cardiac diseaseHip fracture, post-op course gone badPatient’s wishes were clear, family agreedIntensivist “interventions are necessary to
help her”. Whose wishes are being honored?
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Case Report – 68y/o end stage cancer
Pain management issuesPatient/family consensus – pain control overnight, then home with Hospice
Admitting physician “we can fix this”One week hospitalization with supportive care interventions
Whose agenda is it?
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Patient-CenteredRespect patients’ beliefs - ethical, religious
Honor the patient’s wishesHelp family through the processConsider Ethics Committee consultation if there are conflicts
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Not Physician-CenteredObjective advice and supportWe don’t facilitate death, but we can actively comfort patients at the end of life
Don’t let technology and medical advances stand in the way of patients’ right to die.
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Have the ConversationIn times of health as well as illnessAdvanced Directives – even the young
Durable Power of Attorney - sameResuscitation/Code Status - 65+, others with advanced illnesses
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Have the Conversation AgainIn times of health as well as illnessWhen situations changeBuild it into the workflowEMR structured data sectionReportingPre-visit planning
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Share the WishesPrimary Care PhysicianFamilyLocal hospitalStatewide Health Information Exchange
With each transition of care
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Case Report – 92y/o acute abdomenPatient’s wishes were clearPCP provided support to emphasize patient’s wishes
Hospital service attending kept swaying the family towards intervention “we need to operate, would you rather do nothing and let her suffer?”
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
End of Life Care is an ACTIVE intervention
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
R.I. Living WillRights of the Terminally Ill Act Declaration
http://www.health.ri.gov/forms/legal/LivingWill.pdfA DeclarationI voluntarily make known my desire
that my dying shall not be artificially prolonged…
If I should have an incurable or irreversible condition that will cause my death…CSI-RI Learning Collaborative October 9, 2014 David
Gorelick, MD, FACP
R.I. Durable Power Of Attorney For Health Care
http://www.health.ri.gov/forms/legal/DurablePowerOfAttorneyForHealthCare.pdf
An Advanced Care DirectiveAppointment of Health Care Agent to make
health care decisions if you can no longer make decisions
Two qualified witnesses or one notary public must sign
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
R.I. Durable Power Of Attorney For Health Care
If I am close to death and life support would only prolong my dying
If I am unconscious and it is very unlikely that I will ever become conscious again
If I have a progressive illness that will be fatal and is in an advanced stageCSI-RI Learning Collaborative October 9, 2014 David
Gorelick, MD, FACP
Living Will/POA – Code Status?Distinguish between “life support” when
life brings you towards the end with a terminal condition vs Code Status
DNR should not have a menu of optionsComfort One
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Comfort Onehttp://www.health.ri.gov/publications/
handbooks/ComfortOneEMSDoNotResusitateProgram.pdf
Bracelet applied to the patientEMS can provide care without “threat”
of resuscitationTerminal illness diagnosisAdvanced age, frail, failing to thrive?
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Comfort One Bracelet
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
MOLSTMedical Orders for Life-Sustaining
Treatmenthttp://www.health.ri.gov/lifestages/
death/about/medicalordersforlifesustainingtreatment/
http://www.health.ri.gov/forms/medical/OrdersForLifeSustainingTreatment.pdf
Stand-alone, portable orders that follow the patient from facility to facility.
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
MOLST - elementsCPRMedical InterventionsTransfer to HospitalArtificial NutritionArtificial HydrationAdvance Directive
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
Transition of CareInterpreting patient’s wishes as they apply
to the current situation may be a challengeInvolve the familyInvolve the healthcare team
Inpatient MD’s, RN’sNCM’s – inpatient and outpatientPCP’sClergy
Leave egos at the door – focus on the patient
CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP
CSI-RI Learning Collaborative October 9, 2014
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