Advance Care Planning for Very Ill Clients

Dick Sayre, Attorney at Law WA POLST Education Task Force Jim Shaw, MD WA POLST Education Task Force

Objectives

n How POLST and Advance Directives work together n Who should have a POLST, and who shouldn’t n Examine the effectiveness of POLST and Advance Directives n Using the POLST

Advance Directives:Types

 For hypothetical conditions the patient does not have currently  Health Care Directive or “Living Will”  Durable Power of Attorney for Healthcare with Written Instructions 

All of you should have one!!

Advance Directive Limitations

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

How Advance Directives and POLST Work Together

Adapted with permission from California POLST Education Program © January 2010 Coalition for Compassionate Care of California

Physician Orders for Life Sustaining Treatment (POLST)

What is POLST?

n n n n n

Current

physician orders for end-of life care Single, easily recognizable form for all pre-hospital EMS personnel Portable: Travels with patient Can translate an Advance Directive into physician orders REMEMBER: Conversations for goals of care come first!

POLST in Oregon: Good Results

n n n n Study of 180 nursing home residents requesting comfort measures only, transfer to hospital only if comfort measures fail, and do not resuscitate: two percent were hospitalized to extend their lives none were resuscitated against their wishes

Tolle SW, Tiden VP, Dunn P, & Nelson C (1998) J Am Geriatrics Soc, 48,1219-1225

– www.polst.org

for more references

How POLST Works

POLST: Who Should Have One?

n Anyone “you anticipate might die within the next year” n Anyone choosing: – Do not attempt resuscitation – No code – Allow natural death n Anyone choosing to limit medical interventions

n “Summary of Goals” - an opportunity exists in this box to summarize the medical condition(s) and goals of care n WA recently moved this to top of form

POLST Form Part A

n Resuscitation: Includes EMS n Patient has no pulse and is not breathing – Attempt Resuscitation – Do Not Attempt Resuscitation(DNAR) Allow Natural Death, (AND)

POLST Form Part B

n Medical Interventions: Includes EMS: Patient/resident has pulse and/respirations n n n

Comfort Measures Only:

Medication by any route, positioning, wound care, other measures to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction as needed for comfort.

Patient prefers no transfer: EMS contact medical

control to determine if transport indicated for comfort.

Limited additional interventions:

Includes care above. Medical treatment, IV fluids and cardiac monitor as indicated. Do not use intubation or mechanical ventilation.

Transfer if indicated, avoid ICU if possible.

Full Treatment/Resuscitation:

All care above plus intubation and defib.

Transfer to hospital if indicated. Includes intensive care.

DNR DOES NOT MEAN D O N OT T REAT

• 78 % of long term care residents with DNR marked an option above the minimum • 20% of hospice patients want limited additional interventions

POLST Form Part C

n Discussed with: n Signatures n Clarifying language when using surrogate decision-maker n Accompanying documents: encouraged to attach ADs

Prevalence, Availability, and Consistency of Advance Directives in La Crosse, County after the creation of an ACP system in ’91-’93

*Hammes BJ, Rooney BL. Death and end-of-life planning in one Midwestern community.

Arch Intern Med.

1998;158:383-390. **Hammes BJ, Rooney BL, Gundrum JD. A comparative, retrospective, observational study of the prevalence, availability, and utility of advance care planning in a county that implemented an advance care planning microsystem. J

AGS

. 2010;58:1249-1255.

Additional Data Regarding LADS II…’07-’08 (N=400)

• 67% of decedents had a POLST document.

• 98.5% of POLST forms were in the medical record of the health organization where the person died.

• The most recent POLST form was completed 4.5 months prior to death.

• 96% of all decedents had either an AD or a POLST form at the time of death.

Comparison of POLST vs. AD Only LADS II ‘07-’08 (N = 400) POLST (N= 268)

• Older: Mean age 83

AD only (N= 116)

• Younger: Mean age 77 • More likely to die of chronic or terminal illness (97% ) • More likely to die in LTC or at home (84%) • 30% of POLST forms were completed in consultation with a patient’s health care agent • More deaths from sudden or traumatic causes (18%) • More likely to die in the hospital (59%) or inpatient hospice (23%)

Does POLST work in La Crosse?

• POLST has great flexibility: Of 268 deaths where patient had a POLST, we found 34 different combinations of orders from the 4 sections. 65% requested some treatment beyond comfort measures only.

• POLST is highly prevalent: 67% of all deaths (268) from all settings had a POLST and of these 243 also had a POAHC.

• POLST is available: The POLST form was available to the health professional where the patient died.

• POLST is honored: If patients wanted treatment they always received it. If they did not want it, they almost never received it. We could only find 2 cases where a patient’s desires not to be hospitalized were not honored.

POLST in WA State

Washington State Natural Death Act

n 1992 RCW Amendment – Provided Direction to DOH n EMS Providers: – Adopt guidelines for EMS Personnel • Respond to written Do Not Resuscitate (DNR) Orders – Personnel legally recognize pre hospital DNR Orders

2000 Amendment to RCW 43.70.480

Amended the Emergency Medical Personnel-Futile treatment and natural death directives Guidelines  Guidelines shall include development of a single form that shall be used statewide

Amendment Implementation Actions Taken by Dept. of Health

n Spokane Pilot n Pilot Project Objectives – Implement POLST to Reflect wishes of patient – Created a portable document that accompanied patient in Pre hospital, Hospital and Long Term Care settings – Patient’s wishes are respected

Post-Pilot Actions

n n n n Implemented the POLST Form Statewide DOH-EMS and Trauma System Office conducted in-depth training of EMS and Trauma Care Personnel Single, easily recognizable form for all pre-hospital EMS personnel Partnership with Washington State Medical Association (WSMA) formed

Lessons Learned

n n n n Professional collaboration: health care, law, legislative, religious, disabled, organizational Education and language Key champions, individuals as well organizations (WSMA, DOH, WSHA, DSHS, Elder Law) Addressing misconceptions and misuse

Questions