Transcript of The NC MOST Form: What’s in it for LTC facilities, patients families & providers? NC Health Care...
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- The NC MOST Form: Whats in it for LTC facilities, patients
families & providers? NC Health Care Facilities Association
Webinar August 2, 2012
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- 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
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- In my day, people died.
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- 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.
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- Statistics ~80% wish to die at home Over 85% say they want
spiritual needs met Over 90% want well- managed pain ~25% die at
home ~6% have talked to their minister ~11% have talked to their
MD
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- What has gone wrong? The conversation is not taking place. Why?
Medicare (via PSDA) says Well give you money if you have the
conversation. Reality is Well 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.
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- 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.
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- 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
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- Treatment settings Outpatient settings Emergency rooms ICU
Step-down units hospitalists Med/Surg units Rehab Palliative care
LTC Hospice
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- What happens in the ED? 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 patients care? What is the
appropriate disposition?
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- 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
http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm
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- Its not about the documents! Its about the conversation. Its
about the patients right to choose. How do we communicate our
wishes?
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- Technology of Critical Care www.icu-usa.com/tour
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- Treatment Options CPR Artificial hydration Artificial nutrition
Artificial ventilation Antibiotics Dialysis Chemo/radiation therapy
Pharmaceuticals Pace makers
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- Should everything be done? Knowledge Wisdom
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- 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?
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- What does all this have to do with the National POLST Paradigm
and the NC MOST form? EVERY THING!
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- Basis of POLST Encourages discussion about key end of life care
issues Patients Families or surrogate decision- makers Health care
providers
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- 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.
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- National POLST Paradigm A win-win for everyone
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- POLST History 1991 - Patient Self Determination Act 1991 -
POLST form developed in Oregon 2002 - POST in West Virginia 2007 -
MOST in North Carolina
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- POLST Paradigm 1990
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- Developing Programs *As of January 2011 Endorsed Programs No
Program (Contacts) Designation of POLST Paradigm Program status
based on information available by the program to the Task Force.
National POLST Paradigm Programs*
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- Developing Programs National POLST Paradigm Programs Endorsed
Programs No Program (Contacts) *As of February 2012
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- What fueled the spread of the POLST Paradigm?
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- 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
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- 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 52:14241429, 2004.
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- 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
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- 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
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- MOST: 5 Sections A.Cardiopulmonary Resuscitation (CPR)
B.Medical Interventions C.Antibiotics D.Medically Administered
Fluids & Nutrition E.Discussed with and agreed to by
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- Section A: CARDIOPULMONARY RESUSCITATION Attempt Resuscitation
(CPR) Do Not Attempt Resuscitation (DNR/no CPR) Only one option
should be selected. Only applies if there is no pulse and the
patient has stopped breathing (cardiopulmonary arrest)
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- Survival After Cardiopulmonary Resuscitation (CPR) Generally,
only 10-15% survive to hospital discharge; many with impairments
Lower rates of survival (