Conversations Before the Crisis:

Advance Care Planningand

The POST Projectof the

Palliative Care Partnership of the Roanoke Valley

“Death is an inevitable aspect of the human condition. Dying

badly is not.”

Jennings, et al, 2003

“Things Just Ain’t the Same”

How did we get here?

What is shaping EOL Care in America?

• Late 1800’s• Early to mid 1900’s• 21st Century

The Need for Improved Care at the End of Life

Cause of Death/Demographic and Social Trends

Early 1900s Current

Medicine's Focus Comfort Cure

Cause of Death Infectious Diseases/ Communicable Diseases

Chronic Illnesses

Death rate 1720 per 100,000 (1900)

810 per 100, 000 (2009)

Average Life Expectancy

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Site of Death Home Institutions

Caregiver Family Strangers/ Health Care Providers

Disease/Dying Trajectory

Relatively Short Prolonged

“By 2020 about half of all deaths are expected to occur in nursing

homes.”

Source: Sheehan, D. And Schirm, V. End of Life Care of Older Adults. AJN, Nov. 2003, 103, 11, pp. 48-57.

Impact on Death and Dying in America

• Americans living longer• People over 85 yo---fastest growing sector• Living longer with progressive and eventually

fatal illness---marked functional dependency• Isolation from death experience--increased

risk of profound emotional grief response

Impact (cont.)

• Families live far apart• Elderly infirmed caring for elderly spouse• Shift to curative focus has overshadowed the

obligation to provide appropriate Tx and compassionate care

• The allure that medical technology can defer death indefinitely

Death and Dying in America (cont.)

• Disparity between the way people die/the way they want to die

• Patient/family perspective

Source: Hunter Groninger, MD, “Palliative Care and the Patient Navigator” , March 2009. Used with permission.

SUPPORT Study…Dying in Hospitals is Unsatisfactory

• 53% of MDs were unaware when patients had DNR orders

• 46% DNR orders written within 2 days of death• 38% of patients who died spent at least 10 days

in an ICU• More than 50% of hospitalized patients had

moderate to severe pain in the last 3 days of lifeStudy to Understand Prognoses & Preferences for Outcomes & Risks of

Treatment, 1995

“ People want to die at home but most don’t. They want to die free from pain, but too many

don’t. At the same time, most people don’t want to talk about their wishes--or about dying

at all--and they either don’t know about options for EOL care or they don’t ask for

them. . . At best, Americans have only a fair chance of receiving good EOL care.”

--Judith Peres

Before There is a Crisis:

Turning Your Wishes for End of Life Care into Actionable Advance

Directives:

The POST Paradigm

Is it enough to have a written Advance Directive?

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An Index Case

Mr. Jan, a 71-year-old male with severe COPD and mild dementia, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jan developed increasing SOB and decreasing LOC over 24 hours. The nursing facility staff called EMS who found the patient unresponsive, with a RR of 8 and an O2 sat at 85% on room air. Although Mr. Jan had discussed his desire to forgo aggressive, life-sustaining measures with his family and nursing personnel, the nursing facility staff did not document his preferences, inform the emergency team about them, or mention his do-not-resuscitate order.

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After EMS was unable to intubate him at the scene, they inserted an oral airway, bagged, and transported the patient to the emergency department (2nd hospital). Mr. Jan remained unresponsive. He was afebrile, with a systolic BP of 190 mm Hg, P of 105 , RR of 8, and an O2 sat of 88% despite supplemental oxygen. He had diminished breath sounds without wheezes, and a chest X-ray showed large lung volumes without consolidation. Arterial blood gases showed marked respiratory acidosis. The emergency department physician wrote, “full code for now, status unclear.” The staff intubated and sedated Mr. Jan and transferred him to the intensive care unit.

Lynn, et al. Ann Intern Med 2003;138:812-818.

What went wrong?(Could this happen in Virginia?)

• Advance directives not documented• DNR order not communicated in transfer• Fragmentation in care (2 hospitals)• Overtreatment against patient’s wishes• Unnecessary pain and suffering• System-wide failure to respect pt’s wishes

– Failure to plan ahead for contingencies– No system for transfer of plan

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What is POST?• A physician order• Can be completed by a non-physician

provider but must be signed by qualified MD or DO (Osteopath)

• Complements, but does not replace, advance directives

• Voluntary use• Recognized by EMS and participating

facilities as a valid DDNR 22

Does the POST Process Work?

• 2 Studies reported in July JAGS in July 2010:– MR review of 1711 nursing facility patients in

multiple states, including WV– MR review of 400 patients who died in hospital,

NH and community in La Crosse, WI

Results:

• Those with a POLST form indicating Comfort Care were far less likely to receive unwanted hospitalizations and medical interventions than those who had only a DNR order

• Those requesting fewer medical interventions continued to receive pain and symptom mgt. identical to those without POLST orders.

• Those with POLST forms were more likely to have orders about medical interventions in addition to resuscitation (98% vs. 16%)

Results Continued

• Those requesting full tx on their POLST—had same level of tx as those pts. with traditional orders for full tx.

Bottom Line

• POLST/POST is achieving its goal of honoring tx preferences of those with advanced illness or frailty.

• Plus----”POLST/POST serves as catalyst for conversations in which pts. talk with their loved ones and their health care professionals about what they really want”– Alvin Moss, MD; Medical Dir. Of Center for Health Ethics and Law of WV University

POST Pilot Project• POST (POLST) orders legally

recognized in several states, including WV and NC

• Roanoke Valley is conducting a POST pilot project; complete in May 2011

• Plan to make POST a legal document recognized throughout Virginia

• A number of statewide hospitals/nursing homes/hospices, and other agencies are on state POST Task force

POST is for…

Seriously ill patients*Terminally ill patients

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* chronic, progressive disease/s

Purpose of POST• To provide a mechanism to communicate

patients’ preferences for end-of-life treatment across treatment settings

• To improve implementation of advance care planning

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Living Will* v. POSTLiving Will

• For every adult• Requires decisions about

myriad of future treatments• Clear statement of

preferences• Needs to be retrieved• Requires interpretation

POST• For the seriously ill• Decisions among presented

options• Checking of preferred boxes

• Stays with the patient• A physician’s order

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*Fagerlin & Schneider. Enough: The Failure of the Living Will.Hastings Center Report 2004;34:30-42.

Why POST Works…

• MUST accompany patient• Contains specifics• Physician’s order—no interpretation

is needed–Participating facilities/agencies have

agreed to accept POST order sheet

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Prompt for POST Completion

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Would you be surprised if this patient died in the next year?

POST: Who Should Have One?

• Anyone choosing “Do Not Resuscitate”• Anyone choosing to limit medical

interventions• Anyone eligible/residing in a LTC facility• Anyone who might die within the next year

POST Form

Section A: Resuscitation

• Only section applicable to EMS• DNR orders only apply if a person is pulseless and apneic• POST recognized as a valid Virginia DDNR – OEMS approval (Michael Berg)

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Section B

• Review care plan to be sure that palliative care measures available• Institute palliative care measures as needed• If meets admission criteria consider hospice

Section B: Level of Medical Interventions

• Limited Additional Measures– Includes comfort care

described in previous section. However, may also use medical treatment, IV fluids, and cardiac monitoring as indicated.

– Do not use intubation, advanced airway interventions, or mechanical ventilation.

– Transfer to hospital, if indicated. Avoid intensive care.

• Full Treatment

– Includes care described in 2 previous sections.

– Use intubation, advanced airway interventions, mechanical ventilation, and cardiac defibrillation, as indicated.

– Transfer to hospital, if indicated. Include intensive care, if indicated.

Section B: Level of Medical Interventions

• Comfort Measures– Treat with dignity and

respect. Keep clean, warm, and dry.

– Use medication by any route, positioning, wound care and other measures to relieve pain.

– Do not transfer to the hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location.

Section C: Antibiotics

Example of “Other Instructions”: Antibiotics may be used only as needed for comfort.

(E.g., patients susceptible to UTI’s may reserve right to be treated with antibiotic for pain and discomfort.)

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Section D: Artificial Nutrition/Hydration

• These orders pertain to a person who cannot take fluids and food by mouth.

• IV Fluids or Feeding Tube for Defined Trial Period:– Gives option of trying either of these to determine benefit to patient

and/or for recovery from stroke or hydration from vomiting, etc.– Recommended trial for IV fluids = 2 to 7 days– Recommended trial for Feeding Tube = 30 days or less

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Section E: Participants & Physician Signature

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Section F: POST Reviews & Instructions

• Related EOL documents, if any, e.g., Living Will

• Signature of Patient or Legal Representative

• Signature of ACP Facilitator

• Directions for Health Care Professionals

POST Form Shall Always Accompany Patient/Resident When Transferred or

Discharged!*

* Note: Preferable to transfer with original current copy, but legible copies are to be honored as though

they are the original.45

On the top of the transfer packet!

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Some Interim Results of Roanoke Pilot Project

• End user training for over 600 clinical staff at participating facilities/agencies

• QI data collected from medical records of nearly 100 residents/patients with POST forms:– Most forms filled out correctly– POST orders followed as written in almost all cases– Problem areas id’d and addressed

• Patient/Family Satisfaction Surveys: Almost all rate the ACP session favorably

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Moving POST into Other Areas of Virginia

• POST State Stakeholders• Groups/organizations in 8 additional localities

are planning/conducting POST Pilot Projects over the next 2 years

• Goal: Work with stakeholders and lawmakers to make POST a legally sanctioned document that provides consistency, portability as well immunity to those signing a POST form and those who carry out the orders on the form.

Early Success Story

Some of the Successes

• So far, value of form recognized by clinicians– Many PCP’s at nursing home requesting that

ACPF’s have POST ACP sessions • Value of the RC Advance Care Planning

Process (with or without POST form)• ACP Process/POST form has already been

reported to have been successful in guiding appropriate end of life care based on patient’s wishes

Some of the Challenges• Form development

– Compliance with state DDNR and Advance Directives– Changes in DDNR laws– Variance in legal advice from one institution to the other– Requirement by legal counsel to have 2 witness signatures:

national POLST advisors say this will create a significant barrier to having the form completed and confuses the POST medical orders with traditional advance directives.

• Portability of document: may be challenged outside of participating organizations– 1 local hospital that serves a participating nursing home– VAMC---federal regs within their system have slowed down

their being able to fully embrace the POST project by being a participating organization

• Making sure form returns with the patient

Moving POST into Other Areas of Virginia

• POST State Stakeholders• A number of groups/organizations in several

localities are planning POST Pilot Projects over the next 2 years

• Goal: Work with stakeholders and lawmakers to make POST a legally sanctioned document that provides consistency, portability as well immunity to those sign a POST form and those who carry out the orders on the form.,

Take-Home Messages about POST

• POST provides a better means than AD to identify and respect patients’ wishes

• POST completion will improve end-of-life care throughout the system

• Use of POST will require communication to make it work in your community

• Consider joining the POST Virginia Stakeholders Task Force

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RAP on POST!

Want to be trained in Advance Care Planning Facilitation for the Seriously

Ill?

• PCPRV POST Respecting Choices Training• Friday, December 10—FULL!!!• Trainings in Spring and Summer 2011• For any health care professional who wants to

learn Advance Care Planning Facilitation Skills using the Respecting Choices Model

• Contact Laura Pole to register—Lpchef@earthlink.net

Address the Fear

“I’ve Seen It and I’m Not Afraid.”

“Because you made it normal, we could make it holy.”Rachel Naomi Remen, from My Grandfather’s Blessings

Contact Information

Laura Pole, RN, MSN, OCNSPOST Pilot Project Coordinator

Lpchef@earthlink.net

Palliative Care Partnership of the Roanoke Valley

www.pcprv.org