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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 (