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Building a Community Partnership Focused on Advanced Care Planning Lancaster General Health Landis Homes The Evolution of Advance Directives: from Living Wills to POLST Maggie Costella, Lancaster General Hospital Objectives • Understand the purpose of advance directives • Recognize the importance of advance directives • Understand the difference between an advance directive and a POLST HOW AMERICANS DIE 20% of Americans die in intensive care units, part of the 50-60% who die in hospitals 4 Mrs. R . . . • … an 86 year old retired homemaker and widow • Lives in an apartment in a senior living community • Increasing abdominal pain, nausea, and fever • Medical conditions include heart disease (controlled with medications), diabetes (controlled with insulin), and mild forgetfulness • To the emergency department then admitted with diverticulosis and urinary tract infection . . . Mrs. R • Physician says Mrs. R should feel better soon, but asks about resuscitation “if something unexpected happened, her heart stopped, and she died.” • Mrs. R says, “I just want to go back to my apartment. I don’t want to be on any life support machines and I don’t want to think about things like that. My daughter will take care of things if something like that happens.” . . . Mrs. R • How does her family know what to decide? • Do they have the authority to decide? • What documents are most helpful? Patient Decision Making • Every adult person of sound mind has a constitutional right to make decisions regarding his or her care. • A competent patient has the right to refuse treatment or make a bad decision even if it means he/she will die. Advance Care Planning • Advance Directives help care givers know what type of care an individual wants when they cannot speak for themselves. • Advance Directives allow people to retain control over the care they receive. Advance Care Planning • Principles of biomedical ethics: – Autonomy – Beneficence – Non-maleficence – Justice What is an Advance Directive? • A document prepared in advance of the need for health care that expresses an individual’s wishes for future health care • Two types: – Living Will – Health Care Power of Attorney Living Will • A document that expresses wishes for health care when faced with end-of-life decisions • Enables someone to express wishes about: – Artificial nutrition and hydration – Cardiopulmonary resuscitation – Artificial respiration – Other health care services Living Will - When Does It Apply? • Living Wills usually pertain to end of life care • Family members and physicians must follow the instructions in a Living Will when: – The individual is unable to make decisions; and – The individual is either permanently unconscious or suffers from an end-stage medical condition Health Care Power of Attorney • A document that appoints someone to make health care decisions for the individual executing the document. – Not limited to end-of-life decisions. – The person appointed is the “Health Care Agent.” • Health care agents make decisions for the individual when the individual is unable to make his own decisions. Decisions a Health Care Agent can Make • Typically, can make decisions regarding: – Surgery – Continuation or withdrawal of life-sustaining treatment – Admission to a nursing home – Donation of organs Health Care Power of Attorney • As long as an individual is competent, then the individual controls the care she receives. What Happens When There is no Advance Directive? • When an individual is unable to make decisions for themselves and there is no advance directive, the law appoints someone to make decisions. • This person is called a “Health Care Representative.” • Typically, the Health Care Representative is a close family member. Health Care Representative • The law lists who can serve as the health care representative: – Spouse and adult children from a prior relationship – Adult children – Parents – Siblings – Grandchildren – Any adult who knows your values/beliefs (close friend, niece/nephew, etc.) What Decisions Can a HC Representative Make? • Typically, can make most medical decisions, such as: – Consenting to surgery or other medical treatment. – Authorizing admission to a nursing home. What Decisions Can a HC Representative Make? • However, representative cannot withhold or withdraw life-sustaining treatment unless individual is permanently unconscious or suffers from an end-stage medical condition. Multiple Representatives • It is possible to have more than one representative. – For example, if the patient’s spouse is deceased and the patient has three adult children, the three children will make decisions for you. Multiple Representatives • If the health care representatives disagree about what care to provide, the doctor and hospital will follow the majority decision. – For example, if two children want to withdraw lifesustaining treatment, but the third child wants to continue it, the health care provider will withdraw treatment. Relying on a Health Care Representative • John is 55 years old and married with two adult kids. • John divorced his first wife 25 years ago and has two other children from his first marriage. • John does not have an Advance Directive. • John has a heart attack. Cont’d • John is unresponsive and the medical team is concerned about severe brain injury from lack of blood and oxygen. • Medical team thinks it is unlikely John will regain consciousness. • John’s current wife and kids want to withdraw care. • John’s ex-wife and his kids from his first marriage want to continue treatment. Relying on a Health Care Representative • Even though the law appoints a close family member as a representative, it’s still important to have an Advance Directive because: – Family might not know what your treatment wishes are. – Family might disagree on what care is appropriate. – Family members who the patient does not want making decisions for them, might be the ones making decisions. Advance Directives: Limitations • Advance directive may not be available. – Not completed by most adults. • only about 20% of Pennsylvanians have completed – Not transferred between health care settings. • Advance directive may not be specific. – About current diseases or conditions. – Regarding preferences about non-procedural issues. Advance Directives: Limitations • Advance directive may not have resulted in discussion. – Individual just completed form. – Surrogate/family and medical team left to interpret. • Advance directive may not be current; resulting in greater uncertainty about treatment preferences. • Advance directive may not be followed if terminal status unclear. • Advance directive does not immediately translate into physician order. “POLST” A method to define patients’ preferences for end-of-life treatment and communicate them across care settings. Turn treatment preferences and advance directives into medical orders. POLST • Pennsylvania Orders for Life Sustaining Treatment. • Type of advance care planning tool. • Intended for individuals who are ill and have a life expectancy of 1 year. • Does not replace a Living Will or Health Care Power of Attorney. POLST • Current medical orders, not preferences late. • Allows individuals to express type of care desired. – CPR – Artificial Nutrition/Hydration – Full or limited interventions • Transfers with the individual. – Ideal for individuals in nursing homes or rehabilitation centers POLST • Approved, standardized form, bright distinct color. – “Pulsar pink” • Complements advance directives. • The POLST form is kept in a prominent/known place. – Home: refrigerator, bedside table, wall above bed – Health care facility: front of the medical chart POLST is for… • Seriously ill persons. – chronic, progressive disease • Persons with end-stage medical condition. • Terminally ill persons. • Persons with advanced frailty. Use of the POLST form is usually not appropriate for persons with stable medical or functionality problems or who have many years of life expectancy. POLST Form Requirements • Patient name. • Resuscitation orders. • Physician/NP/PA signature. • Patient (or legal medical decision-maker) signature. All other information is optional POLST • Provides medical orders and specific information. – Resuscitation: CPR or Allow Natural Death – Other medical interventions • 3 categories with escalating levels of interventions • May be used to limit medical interventions OR clarify a request for all medically indicated treatments including resuscitation. • Based on conversation for goals of care. Advance Directive or POLST Advance Directive POLST Population All Adults Serious illness or frailty Timeframe Future care/future conditions Current care/current condition Who completes form Individuals/Patients Health Care Professional Where completed Varies Medical setting Resulting product Surrogate appointment and statement of preferences Medical orders based on shared decision-making Surrogate role Cannot complete Can consent if patient lacks capacity* Portability Patient/family responsibility Health Care Professional responsibility Periodic Review Patient/family responsibility Health Care Professional responsibility to initiate Advance Care Planning Age 18 Complete an Advance Directive Update Advance Directive Periodically Diagnosed with Serious or Chronic, Progressive Illness, including Dementia* Consider a POLST Form Treatment Wishes Honored Materials adapted from the Coalition for Compassionate Care of California *Someone for whom you would not be surprised if they died within a year ONE COMMUNITY’S EXPERIENCE WITH POLST NEELOFER SOHAIL, MD, CMD Geriatric Specialists Lancaster General Hospital WHY IT STARTED • ISSUES – Nursing home orders – EMS acceptance of advance directives – Advance directives not present at the right time – Patients were getting unwanted care. HOW IT STARTED Getting together of champions from hospital and SNFs- July 2010 Send out invitations to the SNFs, CCRC’s,EMS, ED staff, Home health agencies, Hospice, adult day care, lawyers. First meeting in October of 2012 with support of the Lancaster Medical Society- Judith Black introduced the community to the POLST A task force was set up with varied members. PROCESS Several groups were assigned with champions to help the process. SNF, Hospital, EMS, Adult Day care and Hospice and home health agencies. Policy and procedures were reviewed by all the involved parties. These were implemented after fine tweaking them for the different facilities. PROCESS • Meetings were set up of the different groups and also of the task force to trouble shoot issues. • A few of the facilities volunteered to be pilot facilities including the hospital. • Transfer of residents started between hospital and pilot SNF facilities. • Education continued- SNFS, hospital and community at large. BARRIERS Physicians Standardization Administration Time to educate and implement Designating a person to initiate and discuss form. Losing the original forms. OVERCOMING THE BARRIERS • Education of nursing home and hospital physicians at varied settings. • Journal club discussion at hospice. • Small groups of champions visiting physician offices. • Medical staff meeting at hospital and SNFs. • Education and modeling by medical directors at their facilities. CONSISTENCY • Standardization of the POLST form as the standard advance directive form in all participating facilities. • Appointing point persons at each of the participating locations to trouble shoot. • Maintaining consistency in placing the form in the patients chart. • Have a process flow for the form. INITIAL PROCESS • Education of administration at facilities about the POLST. • Review with legal at all facilities. • Involvement of the Bar association. • Having combined meetings of the PMS and the Bar association for providers. BARRIERS • A lot of time involvement from all involved. • Issues with physician time and productivity in doing the form with patient or family. • CCRC units needed more time to involve all sections of their communities. WHO IS RESPONSIBLE • Person initiating the form • Person actually doing the form. • Discomfort of non medical personnel at having to do the form. • Physicians not wanting to do the form, difficulty initiating conversations. OTHER ISSUES • Losing the form was a big issue during the transition. • Multiple Pulsar pink copies kept in the chart. • Communication amongst the facilities-having point persons is very important Educate, Educate, Educate Providers (physician, NP, PA) SNU and hospital Nursing staff-SNU, hospital (especially ER and ICU) Social work, administration, others Patients, families, community Importance of having respected physician champion(s), as well as nursing champion(s) and administrative support in facilities AT THIS TIME Landis Homes Conestoga View Willow Valley QV Presbyterian Mennonite Home Luther Acres Masonic Homes St. Anne’s Ephrata Manor United Zion Maple Farms Calvary Fellowship LET US NOT FAIL THE ELDERLY OF THE FUTURE, FOR THEY ARE US 51 POLST impacts on the CCRC Charles Maines, MBA, NHA Director of Admissions\Social Services Landis Homes Champions • Medical director – Dr. Dale Hursh, MD, CMD • Administrator of Healthcare – Ethel Caldwell, RN, NHA • Director of Admissions\Social Services Supported by administration through the Vice President of Operations Building the process • Meeting with the taskforce • Developing policy and procedures • Educate, Educate, Educate Physician educate • Hosted a breakfast for all primary care physicians who attend to patients • Sent a letter signed by the Medical Director regarding POLST to all primary care physicians who attend to patients Team member educate • Department Director\Supervisor meeting • RN\LPN meeting • Social Service department meeting • House meetings Resident\Families Educate • Town meeting • Hosted a education session for residents and their families • Sent a letter regarding POLST to all residents and\or their responsible person Initial implementation • Started in the healthcare in June of 2011 • Started in the personal care home and residential living in October 2011 Ongoing education • All admissions receive The Pink Link to your wishes for care – Information for patients and family members • Review of advanced care planning – At least, quarterly in healthcare – At least, yearly in personal care and residential living Questions: Contact Information • Margaret Costella, JD - Senior Vice President, Legal Services & General Counsel at Lancaster General Hospital – [email protected] • Neelofer Sohail, MD – Geriatric Specialist at Lancaster General Hospital – [email protected] • Charles Maines, MBA, NHA – Director of Admissions\Social Services at Landis Homes – [email protected]