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The New Indiana POST Program: Improving the Care of Seriously Ill Patients Robert Stone MD FAAHPM Medical Director, Palliative Care Indiana University Health Bloomington 1 Objectives 2 Objectives 1. Do we have to talk about dying? Yes. 2. Why? Because talking and planning help. 3. Because dying is different today. 4. Because HOPE is not a plan. 5. What are advance directives? 6. Why POST? 3 “We all know we are going to die, but we don’t believe it.” • Morrie Schwartz, Tuesdays with Morrie 4 Jack and Dorothy Stone 5 Average Human Life Expectancy 30,000 BC 15,000 BC 1,000 BC 2012 Life Expectancy 2010 •Average age at death - 79 years. •If you live to 65, average age at death – 84 •If you live to 80, average age at death – 88 Typical Disease Trajectories to Death: Terminal Illness High Function Low Murtagh F E M et al. Nephrol. Dial. Transplant. 2008;23:3746-3748 © The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: [email protected] Typical Disease Trajectories to Death: Progressive Chronic Disease Murtagh F E M et al. Nephrol. Dial. Transplant. 2008;23:3746-3748 © The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: [email protected] Typical Disease Trajectories to Death: Frailty High Function Low Murtagh F E M et al. Nephrol. Dial. Transplant. 2008;23:3746-3748 © The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: [email protected] Where do you want to die? More than 80% of people say that they want to die at home, BUT…. More than 80% die in an institution. Hospital Nursing Home Home 60% 25% 15% Woody Allen “It's not that I'm afraid to die, I just don't want to be there when it happens.” Traditional Approaches •Advance Directives –Appointment of Health Care Representative or POA-HC –Living Will •Code status orders –DNR vs Full Code –Out of hospital DNR 14 Where’s That Advance Care Directive? Paula Span, New York Times 10/17/2013 15 The POST Paradigm POST = Physician Orders for Scope of Treatment Converts treatment preferences into medical orders Who: Terminal Illness, Progressive Chronic Disease, and Frailty Preferences to accept or decline treatments Transfers across treatment settings with patient Recognizable, standardized form 16 Section A: CPR Orders • When does Section A apply? – When patient has no pulse and is not breathing Section B: Medical Interventions • When does section B apply? – When the patient still has a PULSE and is/is not breathing Section B: Comfort Measures • Requires active interventions to keep the patient comfortable. • Transfer to hospital only if comfort needs can not be met in current location. For example: • Uncontrolled symptoms (pain, shortness of breath) • Uncontrolled bleeding • Laceration • Fracture • In general = No ICU Does not mean do not treat! Section C: Antibiotics • Antibiotics for Comfort – Examples: Urinary tract infection; wound infection – Literature suggests antibiotics are NOT needed to ensure comfort in a patient with pneumonia • Consistent with treatment goals—see Section B – Stabilize condition – Cure and prolong life if possible Section D: Artificial Nutrition • Discuss risks and benefits of feeding tubes • For trial periods, discuss the goals of the trial and when you will re-evaluate Documentation of Discussion and Patient Signature • Patient/Representative Signature is required Section F: Physician Signature • Physician Signature required • Cannot be signed by NP or PA Who can/should have a POST? – A terminal condition, like cancer – An advanced chronic progressive illness, like severe emphysema, heart, liver, or kidney failure – Advanced frailty, like dementia – Patients who are seriously ill and whose death within one year would NOT be a surprise to their physician. Who can prepare a POST form? • Form can be prepared by a physician or designee (e.g., nurse, social worker, chaplain) – Should not be filled out by attorneys, patients, or family members without physician or designee. • Requires signature of patient or representative. • Requires physician signature to take effect. What if the patient lacks decisionmaking capacity? • May be completed by legal representative – Health Care Representative (see back of form) – Health Care Power of Attorney – Court appointed guardian – But not any family member who has no legal authority* • Orders should be based on patient’s expressed preferences, if known How does the POST work in the hospital setting? • Form is valid in ALL settings – Even if MD who signs it lacks admitting privileges • Orders should be used to guide treatment plan • POST can be revoked or modified if desired How do we handle the form? – Original POST is property of patient – Keep with medications or in refrigerator •Bright pink is recommended, but not required •Photocopies or faxes are valid •Copies to all treating doctors •File with local ambulance or fire department Where else can we turn for help? • Respecting Choices www.RespectingChoices.org • The Conversation Project www.TheConversationProject.org • IU Health Bloomington Advance Directives Hotline: 812-353-9262 • Advance Directives Resource Center www.in.gov/isdh/25880.htm 30 Conclusion • POST offers advantages over traditional practices • Indiana POST is available for use by qualified patients • POST provides clinicians across settings with information about the patient’s plan of care The first step is to have the conversation! George Burns 1896-1996 “Statistics show, if you live to be 100, you've got it made. Very few people die past that age.” The New Indiana POST Program: Improving the Care of Seriously Ill Patients Robert Stone MD FAAHPM Medical Director, Palliative Care Indiana University Health Bloomington 33