Transcript Advance directives, advance care planning, and POLST

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Advance directives, advance
care planning, and POLST
Alexander R Nesbitt MD
Susquehanna Hospice and Palliative Care
[email protected]
Goals
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Understand history, benefits and limitations of
traditional advance directives
Understand the process of advance care
planning
Understand the role of the POLST form in
advance care planning
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Documents
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Living will
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Originated with legal sentinel cases surrounding
right to decline rx
Focus on the document
Legal-most done in attorneys offices
Focus on the individual autonomy, the patient and
their rights
Focus on terminally ill, permanent state of
unconsciousness
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Living will-problems
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Despite more than four decades and over
100 million dollars promoting and marketing
living will concept, and…
Despite endorsement of all major medical,
legal, senior citizen, and other organizations,
and ….
Despite PSDA 1990….
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Most Americans do NOT have completed living
wills or other formal written advance
directives.
~ 30 % of Americans (more for upper middle
class white americans, less for non white
americans).
But that is not the worst problem….
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Most Americans who HAVE done an advance
directive do not have it available in the
hospital when decisions are being made (less
than 20%....maybe MUCH less).
But that is not the worst problem…..
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Of those who HAVE done an advance directive,
and who HAVE it available in the hospital
when decisions need to be made, VERY
OFTEN it does NOT provide the answer to “
what should we do for Fred?”
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Fred’s advance directive
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“If you have an end-stage medical condition
or are permanently unconscious and there is
no realistic hope of significant recovery…”
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I do not want tube feedings given
Is Fred in an end stage medical
condition…permanently unconscious…have hope
of significant recovery ?
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SUPPORT study, HELP study
Most (70-78%) people desire to rely on
individual they trust who can hear information
and make difficult decisions that reflect their
values and are in their best interest, rather
than bind the physicians by a specific
prescription for preferred medical choices.
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Surrogate
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Durable power of attorney for health care
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“Health care agent”
Designated by the capable patient to speak for
them when the patient is incapable of
deciding/speaking for themselves.
Can make health care decisions for patient that
the capable patient would make for themselves
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Health Care agent
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Not necessarily spouse, oldest child, person
you love the most
Person who can speak and advocate for you
even in emotionally difficult situation, with
complex medical information and uncertainty
about outcomes
Person who can carry out your wishes even if
difficult
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Health Care representative
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Default list to identify surrogate decision
maker
Able to make health care decisions for
incapacitated patient
Limits to ability to make some decisions if
patient not endstage medical condition
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Health care representative
Spouse/adult child not child of spouse
Adult child
Parent
Adult sibling
Adult grandchild
Adult with knowledge of patient
wishes/values
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Importance of Agent
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Naming agent (deciding who you want)
Documenting your choice of agent
Talking to your agent about values,
preferences….what kind of living would be
okay, what is most important for you (not
necessarily list of desired medical
interventions)
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Special population
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Advanced chronic disease
Long term care, ALF
The ‘surprise’ question…would you be
surprised if this person died within the next
year?
Includes but NOT limited to terminally ill
patients
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What happened ?
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Had agent
Had advance directive
Had ‘no code’ order
He and his family tried to do everything right
We (the medical system) got it wrong
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To prevent this, need system to convey
patient preferences that is...
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Accurate and applicable now, not in some
future condition
Actionable- you look at the form, you know
what to do
Accessible- there with the patient when you
need it, wherever the patient is; nursing
home, ER, hospital bed
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POLST
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Brightly colored pink card stock paper, easily
identified in the medical record
Travels with the patient when transferred
from site to site (nursing home, ER, hospital)
Actionable physician orders for specific
medical interventions
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Benefits of POLST
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Increase the likelihood of care given being
concordant with patient desires
Allows for ‘titration’ of care to match patient
wishes; choose what interventions are
desired or not desired.
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77% DNR patients wanted more than minimum
choice of other care
47% of ‘full code’ patients wanted less than
maximum choice of other care
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Limitations of POLST
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Does not name agent/HCPOA….this must be
designated seperately
NOT for general population
Not actionable outside of hospital/nursing
home without specific EMS medical
command physician order (in PA at present)
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POLST is a piece of paper, it is NOT the
main thing
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The DISCUSSION with the patient, the
family, the surrogate IS the main thing……the
document reflects this discussion.
A careful, well done facilitated discussion
leading to POLST completion is of primary
importance.
Training of those who will facilitate this
conversation is ESSENTIAL part of POLST
system.
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Conclusion
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In trying to do advance care planning that
matches what most people want, there has
been a move away from a primarily legal,
document driven, individualistic and rights
based approach to a discussion based
process that includes a discussion of values
and desires with the patient, loved ones and
especially their designated surrogate.
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Two phase approach to ACP
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Important for ALL to name agent, document
this choice, and discuss priorities and values
with agent.
Important for the subpopulation at highest
risk of facing these decisions, those with
advanced disease, especially those in skilled
nursing units, to have the opportunity to have
a facilitated conversation and complete a
POLST document that will be honored in the
health system that cares for them.
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Who will create a system to make this
possible for patients in your world?
Alexander R Nesbitt MD
Susquehanna Hospice and Palliative Care
[email protected]
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