Transcript NC Health Care Facilities Association presentation draft

The NC MOST Form:
What’s in it for LTC facilities, patients
families & providers?
NC Health Care Facilities Association Webinar
August 2, 2012
With thanks to contributors…
Anthony J. Caprio, MD
Assistant Professor of Medicine
Division of Geriatric Medicine
Center for Aging and Health
Palliative Care Consultation Service
University of North Carolina- Chapel Hill
John C. Ropp, III, MD, Chairman, SC CSI
“In my day, people died.”
The Problem
• Too many people are dying in places they
would not choose, in ways they would not
want, surrounded by strangers, their wishes
undocumented, unknown and, therefore,
often not honored.
• What we say we want is not what we get. In
fact, what we get is often the exact opposite
of what we would want.
Statistics
 ~80% wish to die at home
 ~25% die at home
 Over 85% say they want
spiritual needs met
 ~6% have talked to their
minister
 Over 90% want wellmanaged pain
 ~11% have talked to their
MD
What has gone wrong?
• The conversation is not taking place. Why?
• Medicare (via PSDA) says “We’ll give you money if you
have the conversation.”
• Reality is “We’ll take the money and hand out the
documents.”
• Wrong place, wrong time, wrong person, wrong
mechanisms.
• Current EOL Care often does not reflect patients’
values and preferences.
• EOL Care costs a lot of money compared to other
healthcare expenditures.
Language & setting matter….
• “Would you like information about advance
directives?” (Pt: “What does THAT mean?)
• “I need a copy of your Living Will” (WHY?)
OR
• “We want to provide you with the best care possible.
These documents will help us understand and honor
your wishes.”
• “Have you talked with your family & physician about
the kind of care you want? This information may
help.”
Conveyor Belt??
• You may have a good relationship with your
PCP, however…..
• Count the number of specialists and
treatment settings the patient encounters…..
• Stepping into a modern day emergency center
is like stepping onto a moving train.
David Blackmon, MDiv, Asheville, NC
Treatment settings
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Outpatient settings
Emergency rooms
ICU
Step-down units – hospitalists
Med/Surg units
Rehab
Palliative care
LTC
Hospice
What happens in the ED?
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Why is this patient here?
What does this patient want?
How aggressive should we be?
Do I intubate this patient?
Who is involved in this patient’s care?
What is the appropriate disposition?
Limitations of Advance Directives
May not be available when needed
May not be specific enough
Does not translate immediately
into medical order
Literature Review on Advance Directives, June 2007
http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm
It’s not about the documents!
It’s about the conversation.
It’s about the patient’s right to choose.
How do we communicate our wishes?
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Technology of Critical Care
www.icu-usa.com/tour
•
Treatment Options
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CPR
Artificial hydration
Artificial nutrition
Artificial ventilation
Antibiotics
Dialysis
Chemo/radiation therapy
Pharmaceuticals
Pace makers
Should ‘everything’ be done?
Knowledge
Wisdom
When is Enough Enough?
The Ethics of Over-treating or
Under-Treating Patients at the End of Life:
Do good; Do no harm; Prevent harm
Right vs. Risk
Is it time for us to look at what we are
doing and why we are doing it?
What does all this have to do with
the National POLST Paradigm
and the
NC MOST form?
EVERY THING!
Basis of POLST
Encourages discussion about key end of life
care issues
Patients
Health care
providers
Families or
surrogate
decisionmakers
POLST Paradigm Purpose
The Physician Orders for Life-Sustaining Treatment
(POLST) Paradigm program is designed to improve the
quality of care people receive at the end of life.
It is based on effective communication of patient
wishes, documentation of medical orders on a brightly
colored form and a promise by health care
professionals to honor these wishes. It is a win-win for
all involved.
National POLST Paradigm
A win-win
for
everyone
POLST History
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1991 - Patient Self Determination Act
1991 - POLST form developed in Oregon
2002 - POST in West Virginia
2007 - MOST in North Carolina
POLST Paradigm 1990
National POLST Paradigm Programs*
Endorsed Programs
Developing Programs
No Program (Contacts)
*As of January
2011
Designation of POLST Paradigm Program status based on
information available by the program to the Task Force.
National POLST Paradigm Programs
Endorsed Programs
Developing Programs
No Program (Contacts)
*As of February
2012
What fueled the spread of
the POLST Paradigm?
Do Not Resuscitate (DNR) Order
• Medical Order
• Issued by a physician (NP or
PA)
• Not hypothetical;
immediately “in effect”
• No interpretation,
immediately directs care in
the event of a cardiac arrest
Beyond Resuscitation
• Except in the event of cardiopulmonary arrest,
resuscitation orders do not direct other treatments
– Some patients desire an attempt of resuscitation but want to
limit other types of treatment
– DNR does not necessarily imply other treatment limitations
(DNR ≠ Do Not Treat)
• What other kinds of treatments might the patient
receive (or not receive) if they had a DNR order?
Tanabe M. Annals of Long Term Care 2004;12:42-45
Zweig SC, et al. J Am Geriatr Soc. Jan 2004;52(1):51-58.
Hickman SE, et al. J Am Geriatr Soc 52:1424–1429, 2004.
Medial Orders for Scope of Treatment
(MOST) form
• More than a DNR order
• Guide care even when
patient has not arrested
• Options to receive or
withhold treatments
• Avoid inappropriately
limiting or providing other
types of treatments
Pink MOST Form
• Identifiable: consistent pink color
• Flexible: allows accepting or refusing treatments
• Actionable: medical orders
• Up-to-date: reviewed regularly
• Portable: transfer across health care settings
MOST: 5 Sections
A. Cardiopulmonary Resuscitation (CPR)
B. Medical Interventions
C. Antibiotics
D. Medically Administered Fluids & Nutrition
E. Discussed with and agreed to by…
Section A: CARDIOPULMONARY
RESUSCITATION
 Attempt Resuscitation (CPR)
 Do Not Attempt Resuscitation
(DNR/no CPR)
•
Only one option should be
selected.
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Only applies if there is no pulse
and the patient has stopped
breathing
(cardiopulmonary arrest)
Survival After Cardiopulmonary
Resuscitation (CPR)
• Generally, only 10-15% survive to hospital
discharge; many with impairments
• Lower rates of survival (<5%)
– Unwitnessed arrest
– Certain types of heart rhythms
– Multiple chronic diseases
• Survival for nursing home patients 0-3%
Inaccurate Perceptions of Survival
• General belief of 65%
survival after CPR
• 67% of resuscitations
successful on TV
• Probability of survival
influences choices
– Nearly one-half of older
adults changed their mind
about wanting CPR after
hearing about the true
probability of survival
NEJM 1996: 334:1578-1582
NEJM 1994; 330:545-549
Goals of Medical Care
•
Prioritized goals provide context for medical
decision making
1) Longevity
2) Function (maintain/restore)
3) Comfort
•
Rarely, can all three goals be maximized
simultaneously
•
As clinical circumstances change, goals are
reprioritized
J Am Geriatr Soc 1999;47(2):227-230
Section B: MEDICAL INTERVENTIONS
 Full Scope of Treatment
 Limited Additional Interventions
 Comfort Measures
• Guidance about the intensity of
care and the patient’s goals
• Patient is not experiencing
cardiopulmonary arrest
(No indication for CPR)
Prioritize Goals of Care
1) Longevity
2) Function (maintain/restore)
3) Comfort
J Am Geriatr Soc 1999;47(2):227-230
Full Scope of Treatment
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Intubation/mechanical ventilation
Cardioversion
ICU admission
Transport to the hospital if indicated
All other appropriate treatments
• Patients electing “Full Scope” usually express
longevity as the primary goal of care
Limited Additional Interventions
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No intubation/mechanical ventilation
No cardioversion
Would likely not be admitted to the ICU
Transport to the hospital if indicated
“Other instructions” can be used for clarifications
• Goals of Care
– Usually do not prioritize longevity as their major goal
– May express other goals like maintaining or restoring
function
– May opt for therapeutic trials and withdraw therapies if
they are ineffective or become burdensome
Comfort Measures
• These patients prioritize comfort as their most
important goal of care
• Care is focused exclusively on relieving distressing
symptoms
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No intubation/mechanical ventilation
No cardioversion
No ICU admissions
Transport to the hospital ONLY if comfort needs can
not be met in the current location
SECTION B
POLST USERS WITH COMFORT MEASURES ONLY
•67% less likely to receive life sustaining
medical interventions compared to POLST full
treatment.
•Research shows that most people select
“limited additional interventions.”
P<0.004
Section C: ANTIOBIOTICS
 To receive antibiotics if life
can be prolonged
 To determine use or
limitation of antibiotics when
infection occurs
 No antibiotics, in which case
other measures would be
used to relieve symptoms
Section D: MEDICALLY ADMINSTERED
FLUIDS AND NUTRITION
• IV fluids options:
 To receive if indicated
 To receive for a defined trial
period
 No IV fluids
• Feeding tube options:
 To receive if indicated
 To receive for a defined trial
period
 No feeding tube
Nutrition and Hydration
Benefits and Burdens
• Often religious and cultural beliefs guide a patient’s decision
• Discussed in the context of goals of medical care
• IV fluids may not promote comfort at the end of life
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Swelling
Shortness of breath
Need for frequent urination.
Excessive secretions
• Feeding Tube decisions are complex
– Promotes longevity in some cases (ie. brain injury)
– No clear survival benefit in advanced dementia
• Comfort care measures: ice chips and mouth care
Trial Periods or TimeLimited Trials
• Not starting and stopping are equivalent
• Emotionally, stopping is often more difficult
• When goal is not achieved, shift focus
• Sometimes difficult to define duration
Section E:
DISCUSSED WITH AND AGREED TO BY:
1.
Patient
2.
Parent or guardian if patient is a minor
3.
Health care agent
4.
Legal guardian
5.
Attorney-in-fact with power to make
health care decisions
6.
Spouse
7.
Majority of patient’s reasonably available
parents and adult children
8.
Majority of patient’s reasonably available
adult siblings
9.
An individual with an established
relationship with the patient who is acting
in good faith and can reliably convey the
wishes of the patient
Revocation of MOST
• MOST no longer reflects
patient’s preferences
• Put line through the front
page and write “void”
• “Form VOIDED” in the
Review section on back of
MOST
– New form completed
– No new form
MOST is . . .
• Optional
– Won’t work for everyone
– Another instrument to help
honor patient wishes
• Identifiable
– Bright pink color
• Flexible
– Accept or reject medical
treatments
– More than resuscitation
preferences
• Portable
– Travels with the patient
– Directs care in a variety of
settings
• Medical Order
– Immediately directs care
• Reviewed Regularly
– Annually
– Changes in health status
– Admissions/discharges
MOST is NOT…
• A replacement for an advance directive
• Intended for those with a low risk of dying
– Rather than progressive decline from chronic disease, healthy patients
are at risk for sudden catastrophic events associated with prognostic
uncertainty
– Likely to benefit more from a Health Care Power of Attorney
• Available for patients to download or from their attorney
– Must be signed as a medical order by a physician, PA, or NP
– Should be completed after a discussion of goals of care, prognosis, and
benefits/burdens of treatments.
WHO SHOULD HAVE A
MOST FORM?
People with….
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Terminal illness
Advanced disease
Prognosis of death within a year
Debilitating chronic progressive
illness
A strong desire to document their
treatment options in the form of a
physician order
North Carolina Compassionate Care Partnership (Working Name)
Executive
Committee
Task Forces
EMS
Education
Education
for LTC/
Assisted
Living
Acute Care
Education
Quality/
Research/
Data
Education for
Professionals
Consumer
Education
Sustainability/
Funding
Registry
Statewide Steering
Committee
Regional Coalitions (7)
The NC Compassionate Care Partnership
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Two year pilot project in Asheville
Endorsed as a developing state in 2007
State is divided into seven regions
Topic task forces include education for EMS;
LTC/ALFs; healthcare professionals;
consumers; acute care settings; quality,
research & data; sustainability & funding and
MOST registry
Educational Initiatives to date
• 2000 – present: RWJ Community EOL Care
Coalitions and Respecting Choices ACP Facilitator
Training
• NCMS – www.ncmedsoc.org
• OEMS - www.ncems.org
• AHEC – conference in Asheville, Charlotte,
Greenville, Raleigh and Wilmington
• Respecting Choices MOST Advance Care Planning
Facilitator Certification Course
• Regional and local initiatives
Goal is to Improve Care
 Measure outcomes
 Determine patterns of care
 Transition patients from one level of care
to another in a timely, appropriate
manner
 Provide feedback
 Revise system as needed
Benefits of POLST/MOST
• Facilitates appropriate EMS tx
• Facilitates HIPAA compliant transfer of
records between healthcare settings
• Centralizes info; facilitates record keeping
• Enhances link among LTC, EMS, ED, ICU,
Palliative Care Services, Hospice
GIVEN AN
OPPORTUNITY
ONLY 12% OF
LONG TERM
SKILLED
NURSING
FACILITY
RESIDENTS
WANT ICU CARE
CAPC & POLST Summary & Conclusions
1. Palliative medicine leaders play key roles in
health system implementations of POLST
Paradigm
2. POLST is associated with reduced unwanted
hospitalizations
3. Electronic registry's can improve access
Take Home Messages
• MOST form provides means to identify and respect
patients’ wishes
• MOST form completion will improve end of life care
throughout the system
• Use of MOST form will require communication to
make it work in your community
• Documentation and transportation mechanisms
• MOST protects patients, providers and systems
Resources
www.polst.org
www.respectingchoices.org
www.ncmedsoc.org
www.cchospice.org
www.caringinfo.org
www.kidneyeol.org
www.compassionandsupport.org
www.coalitionccc.org
www.wvaendoflife.org
Contact Information
Dee Leahman, Director
Community Partnership for End of Life Care
Hospice & Palliative CareCenter
101 Hospice Lane
Winston-Salem, NC 27103
336-331-1317
[email protected]