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Where we’ve been, where we are & where we’re going Susan Tolle, MD Director of the Center for Ethics in Health Care Cornelia Hayes Stevens Chair Professor of Medicine in the Division of General Internal Medicine and Geriatrics, OHSU Susan Tolle has no relevant financial relationships to disclose that would present a conflict of interest POLST PARADIGM PAST Why Developed PRESENT Expanding Education Building Sustainable Programs FUTURE New Innovations e-POLST/EMR Registries QA/QI WHY WAS POLST DEVELOPED? ADVANCE DIRECTIVE POLST For whom For all adults For persons of any age with advanced illness Purpose To express values and appoint a surrogate (future wishes) Medical orders which turn a patient’s values into action (applies today) Guide actions by Emergency Medical Personnel Usually not Yes Guide treatment decisions in the hospital Yes Yes WHAT FUELED THE SPREAD OF THE POLST PARADIGM? EFFECTIVENESS DATA POLST USE IN SNF 1996 0/180 NH residents with POLST orders of DNR/comfort measures only received CPR/ICU 5% died in acute care hospital JAGS 46:1097-1102, 1998 JAGS 58: 1241-1248, 2010 A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physicians Orders for Life-Sustaining Treatment (POLST) Program Susan E. Hickman, PhD, Christine A. Nelson, PhD, RN, Nancy A Perrin, PhD, Alvin H Moss, MD, Bernard J Hammes, PhD, and Susan W. Tolle, MD SECTION B POLST USERS WITH COMFORT MEASURES ONLY •67% less likely to receive life sustaining medical interventions compared to POLST full treatment. P<0.004 CATEGORIES OF LIFE SUSTAINING TREATMENTS JAGS 58: 1241-1248, 2010 . A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physicians Orders for Life-Sustaining Treatment (POLST) Program Susan E. Hickman, PhD, Christine A. Nelson, PhD, RN, Nancy A Perrin, PhD, Alvin H Moss, MD, Bernard J Hammes, PhD, and Susan W. Tolle, MD GIVEN AN OPPORTUNITY ONLY 12% OF LONG TERM SKILLED NURSING FACILITY RESIDENTS WANT ICU CARE 2007 POLST LEADERS NEW ORLEANS National POLST Paradigm Programs Endorsed Programs Developing Programs No Program (Contacts) *As of February 2012 THE PRESENT ADDRESSING COMMONLY ASKED QUESTIONS •Who should have a POLST form? •How do advance directives and POLST work together? HOW ADVANCE DIRECTIVES AND POLST WORK TOGETHER Adapted with permission from California POLST Education Program © January 2010 Coalition for Compassionate Care of California Age 18 Complete and Advance Directive Update Advance Directive Periodically Diagnosed with Advanced Illness or Frailty(at any age) Complete a POLST Form Change in health status May Complete a new POLST Form Treatment Wishes Honored WHO SHOULD HAVE A POLST FORM? ADDRESSING THE NEED FOR EDUCATION VIDEO SHARING EXPERIENCE, POLICIES, DATA & EDUCATIONAL MATERIALS Six core elements of POLST sustainability •Leadership •Organizational Home •Building a sustainable statewide coalition •Legislation–Regulatory •Mobilizing educational resources •Measuring quality performance LEADERSHIP •Succession Planning •Depth •Commitment •Experience •Strong Physician Champion(s) Judy Citko ORGANIZATIONAL HOME •Academic health center •501(c)3 advance care planning community based •Department of Health •State Medical Society •Other ORGANIZATIONAL HOME •Collaborative •Sponsorship Fit with Mission e.g. industry relationships •Coalition Building BUILDING A SUSTAINABLE STATE-WIDE COALITION •Be Inclusive •Effective Structure and Communication •Regularly Scheduled Meetings LEGISLATION REGULATORY •Political Capital •Relationship with state agencies and other entities •EMS structure/relationship MOBILIZING EDUCATIONAL RESOURCES •Volunteers/sharing resources •Infrastructure •Communication Networks •Secure Financial Support MEASURING QUALITY PERFORMANCE •Monitoring •Updating •Effectiveness •Integrating lessons learned THE FUTURE OF THE POLST PARADIGM DEALING WITH THE ISSUE OF FISCAL IMPACT & THE RHETORIC OF PUBLIC POLICY NEW INNOVATIONS e-POLST Setting national standards for EMR’s OHSU Epic EHR Snapshot REGISTRIES Sharing what we have learned QA/QI USING DATA TO GUIDE POLST PARADIGM CHANGE •NEW CALIFORNIA DATA •January 2012 JAMA www.POLST.org Thank you for coming Welcome to the next phase of the National POLST Paradigm