Transcript Action plan
Improving Care at the End of Life: The Chaplain’s Role in Organizational Change NC Chaplains Association Spring Meeting April 26 -27, 2012 Jay Foster, D. Min Chaplain Wake Forest Baptist Health February 2, 2011 Goals, disclaimers, & hopes Goals To share my experience and interest in End of Life Care To share my experience about interdisciplinary team work at the organizational level Disclaimers WFBMC– we have a lot of work to do, and a lot to learn I am neither a business expert nor a clinician– I hope to use my role as chaplain as advocate for change. ○ “Get him on tax evasion,” The Untouchables & my work on Policy Hopes Good energy to learn together about EOLC and Organizational improvements Context In the summer of 2010, the Medical Executive Committee charged the Clinical Ethics Committee with: “determining the best practice for offering alternative and end- of- life care. What would be the best practice for determining patient desires, how best to change provider behavior to determine such desires and how to operationalize such a best practice in our institution.” Why Now? (Nationwide) The charge to the Clinical Ethics Committee is timely and welcome. Recent articles in medical journals and in popular magazines indicate that medical institutions across the country are examining new strategies to provide optimal care for patients with severe illness. Just two recent examples highlight these efforts: “…early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.” --Temel, et. Al NEJM, 2010 Aug. 19:363(3): 733-42 “…in the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.” --Atul Gawande, MD The New Yorker, Aug. 19 2010 “Its not time for palliative care yet...” The New England Journal of Medicine published a study of 151 patients with metastatic non-small-cell lung cancer. This study found that “early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.”[1] [1] Temel, et.al, “Early Palliative Care for Patients with metastatic non-small lung cancer,” NEJM, 2010 Aug 19:363(3): 733-42. What are the problems, really? For the team: Curative VS. Palliative Old model: ○ 1. Curative Treatment ○ 2. Palliative Care ○ 3. Death (in the ICU) Structural and Systemic Problems A new team in the ICU every week Avoidance of discussion of code status until the patient enters the ICU w/ MMP, and then daily discussion of code status until the patient’s surrogate feels browbeaten. Mortality statistics and 30 days For the Family: Don’t give up hope! What did you say? ○ N.80; the “inaccurate interpretations of physician’s prognostications by surrogates arise partly from optimistic biases rather than simply from misunderstandings.” - Zeir, et.al., “Surrogate Decision Maker’s Interpretation of Prognostic Information, in Annals of Internal Medicine, 2012; 156:360-366. Faith based? Really? ○ N.345; “Greater use of positive religious coping was associated with increased preference for heroic measures (38.3% vs. 8.6%) and lower rates of DNR Order completion....” - Phelps, et.al., JAMA. 2009 March 18: 301(11); 1140-1147. Curative Medicine... “We give lip service to the importance of informed consent and fairness and doing no harm, but ultimately these values are outweighed by two seemingly irresistible goals: postponing death and ‘advancing’ medicine. And so long as these goals remain compelling, … informed consent and fairness and protecting the vulnerable… will be slighted.” Deborah Matthieu, in Organ Transplantation: Religious,Ethical and Social Context Moving forward, lets.... Curative AND Palliative New model: ○ Curative Rx Palliative Care ○ Death (at home; palliative care unit; palliative care on the ICU unit; palliative care in the ED) ○ Survive longer on hospice care ○ Patient satisfaction Hope AND Life Recognize how very difficult it is for loved ones to hear bad news, and help them adjust The EOL Task Force Dr. Moskop, chair of the Clinical Ethics Committee, appointed an End-of-Life Care Task Force to address the charge, with Chaplain Jay Foster and Dr. Morgan Bain as co-chairs. Other Task Force members include: •Cathy Jones, MD •Kate Mewhinney, JD •Preston Miller, MD •Terrie Michaels, RN, MSN •Beverly Essick, RN, MSN •John Moskop, PhD •Dee Leahman, MA End-of-Life Care Task Force February 2, 2011 Systems help busy professionals do the right thing Action Plan Groups GROUP 1 – PCS TRIGGERS Dr. Morgan Bain Ms. Chanita Molina Dr. Preston Miller Ms. Suzanne Carroll Ms. Terrie Michaels GROUP 4 – CLINICAL ETHICS CONSULTATION Chaplain Jay Foster Dr. Frank Celestino Dr. John Moskop Ms. Suzanne Carroll GROUP 2 – PALLIATIVE CARE SERVICES Dr. Morgan Bain Dr. Catherine Jones Ms. Cindy Lorenzetti Ms. Jackie Brumbeloe GROUP 5 – STAFF & FAMILY SUPPORT Chaplain Jay Foster Ms. Lib Edwards Ms. Linda Childers Ms. Sarah Grenon Ms. Terrie Michaels GROUP 3 – ADVANCE CARE PLANNING Chaplain Jay Foster Ms. Beverly Essick Ms. Caroline Gentleman Mr. Dee Leahman Ms. Sandy Gammon Layell GROUP 6 – EOL EDUCATION Dr. Morgan Bain Dr. John Moskop Ms. Kate Mewhinney Ms. Keya Eaton The EOL Task Force Status Report Submitted: 10/29/2010 Presented to Medical Executive Committee: 12/15/2010 8-Page Report with 6 Major Areas: 1) Development and implementation of clinical indicators that “trigger” a referral to the Palliative Care Service, conversation about goals of treatment, or advance care planning. 2) Access to Palliative Care Services. 3) Integration of Advance Care Planning in Outpatient & Inpatient Settings. 4) Strengthening of the Clinical Ethics Consultation Service. 5) Development of professional and family bereavement support services. 6) Education for physicians and other providers about issues related to end-of-life care. Advance Care Planning, Best practices 20 years of doing things the wrong way– I was leaning my ladder against the wrong building http://www.youtube.com/watch?v=h2tJOC_yYRw Respecting Choices® Advance Care Planning Design and Implementation Bernard “Bud” Hammes, PhD. Director Linda Briggs, MS, MA, RN, Associate Director Gundersen Lutheran Medical Foundation, Inc. La Crosse, Wisconsin www.respectingchoices.org The Evidence is Clear: The Standard Approaches to Advance Directives have Failed Prevalence of Ads is low…20-30% overall; less than 50% for end-stage illness Ads are often unavailable at the place of treatment…available to MD 25% of time Ads are most often not helpful to guide decision-making…planning is too generic Ads are often not followed…not available, not specific, not understood Wilkinson A, Wenger N, Shugarman LR; U.S. Department of Health and Human Services; RAND Corporation. Literature Review On Advance Directives. http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm. Published June 2008. National information: Research in Action, AHRQ, Issue #12, March 2003 Prevalence, Availability, and Consistency of Advance Directives in La Crosse, County after the creation of an ACP system in ‘91’93 Decedents with ADs No (%) ADs found in the medical record where the person died LADS I * Data collected in ‘95/’96 N=540 LADS II** Data collected in ‘07/’08 N=400 P value 459 (85.0) 360 (90.0) .023 437 (95.2) 358 (99.4) <.001 Treatment decisions found 98% 99.5% 0.13 consistent with *Hammesinstructions BJ, Rooney BL. Death and end-of-life planning in one Midwestern community. Arch Intern Med. 1998;158:383390. **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. JAGS. 2010;58:1249-1255. The Respecting Choices Model in other places The process of planning has been successfully used in multi-cultural places like Australia, Vancouver, and Hawaii. The model is being implemented in large metropolitan areas like the Twin Cities where all major health systems have agreed to use standardized materials, documents, and training. The full model has shown success in Australia. Evaluation of RPC Implementation to Residential Aged Care and Palliative Care Services, 2006. Respecting Patient Choices Web Site. http://www.respectingpatientchoices. org.au /research/evaluations.html#top. Creating Conditions for Change Inspire a shared vision…the importance of leadership Begin with yourself…what are your barriers? What clinical leadership will be required? What organizational leadership will be required? Start small and build a series of systems to hardwire success Invest in human and financial resources 20 The Five Promises Respecting Choices'© five promises of an effective advance care planning system include: Initiate conversations with adults regarding their views about future medical care Assist individuals with advance care planning Make sure plans are clear Assure that plans will be available Appropriately follow plans Respecting Choices © Suggestions to improve the approach to educating healthcare professionals include: Focus on the process of advance care planning rather than the completion of advance directive documents Use a team approach to advance care planning Define roles and responsibilities for the team Provide the team with teaching resources and skills Develop a system for the team to work in Manage and improve practices and systems Key Elements in Designing an Effective ACP Program #1 System Design AD document AD storage & retrieval ACP team & referral #2 ACP Facilitation Skills Education ACP Team Education Other Stakeholders #3 Community Engagement Materials that Engage Strategies to Engage Addressing Diversity #4 Continuous Quality Improvement The Five Promises Pilot Project Design 23 FIRST STEPS • > 55 years old • Healthy or never planned • Integrated as part of routine patient care • Community engagement and motivation NEXT STEPS • Chronic progressive illness with complications • Co-morbidities • Functional decline • Frequent hospital or ED visits LAST STEPS • Frail • Likely to die in next 12 months /elder • Long-term care • May have lost capacity A pilot project for the Triad: A simpler form by July 1, 2012 Participants WFBMC Novant Health NC Bar, Estates Sub- committee Community Partnership for End of Life Care Community Elder Care Attorney Method Review extant forms ○ Respecting Choices ○ St Joseph’s ○ Five Wishes ○ ABA Simplified Form ○ NC Low Literacy Evaluate for ○ Content ○ Simplicity& Comprehensibility Compassion Fatigue: We need a BMW, but we’re driving a Yugo— Richard McQuellon, PhD Recently, a difficult family interaction left a critical care unit struggling to deliver compassionate, professional care while maintaining a safe work environment for nurses. “How do we as nurses remain professional at the bedside on a daily basis, particularly when, in our hearts, we do not see the utility in this continued care?” Several staff members noted that no easy evaluation system was available that allowed staff to “score” the difficulties caused by the family’s fullsupport mind-set. There was no way to grade the stress caused by daily interactions with the family and delivery of full-support techniques to the patient. “ -- Peter Morris and Kathleen Dracup, “Time for a tool to measure moral distress,” in American Journal of Critical Care, 9/28 vol 17 398-401. Discussion.... Thank you very much for your attention... I look forward to your questions, comments and feedback!