Disclosure of Financial Relationships

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1 Implementing the Advance Care Plan & POLST Kenneth Brummel-Smith, M.D. Charlotte Edwards Maguire Professor and Chair, Department of Geriatrics Florida State University College of Medicine Disclosure of Financial Relationships Ken Brummel-Smith, MD, AGSF Has disclosed relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Advisory Board SCAN Health Plan Research Grants/Contracts Retirement Research Foundation Advance Care Planning vs. Advance Directives Goal oriented discussions Occurs dynamically over time Updated with major health changes Involves others as desired by the patient Not simply signing forms Not simply Getting the DNR 1

2 ACP - Goals Name a surrogate decision maker Clarify goals and values Identify care the patient wants and doesn t want Have forms documenting this Prevent later family or legal battles Ultimate goal: support the patient s self-determination Goal Discussions What is most important in your life? What experiences have you had with serious illness or death? Can you imagine health experiences that are worse than death? Is it important to you to: Try to live as long as possible, even with pain or disability? Try treatments for a period of time, but stop if you are suffering? Focus on quality of life and comfort, even if your life is shorter? Have you changed your mind about what matters most in life over time? Definitions Advance Directives Living Will* Durable Power of Attorney for Health Care* Surrogate decision maker* Combination Advance Directives 5 Wishes Advance Care Plan Document Project Grace Online resource - Do Not Resuscitate Order-DNRO ( Yellow Form in FL)** POLST (POST, MOLST) - an actionable advance directive * FL Statue 765; ** FL Statute 401 2

3 Benefits Of Advance Directives May promote discussions between family members and physicians May help clarify preferences May promote discussion of risks and benefits of different treatments May help dispel myths (e.g., CPR success) May lower health care costs Regional Variation Medicare claims data on 1200 pts with AD and 2000 pts w/o AD ( ) Advance directives associated with: Lower hospital costs (-$5585) 10% fewer deaths in hospital 17% higher use of hospice But only in high spending areas (like FL) Nicholas LH. JAMA 2011; 306: Limitations of Advance Directives Usually not available in clinical settings Do not provide clear guidance to EMS personnel Only 20% of older people have them Variations in state forms Terms may be unclear to clinicians Don t work SUPPORT study Angela Fagerlin and Carl E. Schneider, Enough: The Failure of the Living Will, Hastings Center Report 34, no. 2 (2004):

4 Florida Definitions Health care surrogate - someone expressly named to make health care decisions for you Proxy - someone who has not been expressly named Durable power of attorney for health care -essentially the same as a surrogate FL Statutes 765 Choosing a Surrogate Name someone who can be trusted to follow the person s wishes Don t name someone who can t live without you Choose someone available Inform them what you want Who s the Proxy? 1. Legal guardian 2. Spouse 3. Adult child 4. Parent 5. Adult sibling 6. Adult relative 7. Close friend 8. Clinical SW FL Statutes 765 4

5 Florida Case Hanford Pinnette 73 y/o man in Lucerne Hospital in Orlando with end-stage CHF, renal failure and on a vent Had executed an AD and named his wife as surrogate Drs recommended ending life-sustaining Tx in accordance with his living will Wife refused and said she could communicate with him Hospital went to court and won LST was D/C d and he died Why Advance Directives Are Not Followed Drs. (or family) don t think the patient fits the category in the living will Contents of the AD are vague Family member is not available or unable to make the decision Physicians are concerned about legal risks Teno, J Gen Intern Med, 1998;13:439 Purpose of POLST To ensure that patient preferences are followed For patients with life-limiting illness or frailty 2-3 year life expectancy To provide a mechanism to communicate patient preferences for end of life treatment across treatment settings Home Hospital Nursing home 5

6 POLST is NOT an Advance Directive Advance Directive Hypothetical / future condition Instructions to use as guide for decisionmaking Created by patients POLST Current condition Actionable orders integrated in care plan Created by physicians and health professionals What is POLST? A physician order Can be completed by any provider but must be signed by MD Complements, but does not replace, other advance directives Voluntary use, but provides a consistent, easily recognized document 6

7 Percentage of Participants Who Received Less, Same, or More Care than Requested 1. Amount of Care Received Percent Less Than Requested Same as Requested More Than Requested 100% 94% 91% 90% 86% 84% 80% 70% 60% 50% 46% 40% 33% 30% 20% 20% 14% 13% 10% 4% 6% 3% 3% 3% 0% CPR (N=54) Medical Intervention Antibiotics (N=28) IV Fluids (N=38) Feeding Tubes (N=34) (N=54) Areas of Care and Valid Reponses 1 Percentages exclude participants for whom care was not applicable. Lee, Brummel-Smith, Meyer, Drew, London. J Am Geriatr Soc, 2000; 48:1219 Deaths in Hospital Nationally about 33% of people die in a hospital 1 Oregon 18,000 deaths ( ) 2 6.4% of pts with a POLST and Comfort Measure Only died in the hospital 34.2% without a POLST died in the hospital POLST is a process not a form Fromme EK, et al, JAGS 2014; 62: Basis of POLST Discussion regarding advance care preferences With patient With surrogate decision maker (or proxy) if patient does not have capacity to make decision The POLST can be changed by the surrogate, based on proper ethical principles An authentic wish 7

8 Requirements for a Valid Form Patient identifying information Treatment Orders Physician signature * Patient (or surrogate) signature ** Other optional information * In some states an NP or PA ** National POLST Paradigm recommendation POLST Categories* Section A: Resuscitation or DNR Section B: Level of medical intervention Section C: Artificial nutrition desires Section D: Hospice care* Section E: Documentation of discussion Some states include antibiotics * In the current FL form Section A: Resuscitation Resuscitate Do Not Resuscitate (DNR) Some states have DNAR Do Not Attempt Resuscitation Orders apply if a person is pulseless and/or apneic Some would like to change to AND Allow Natural Death 8

9 Section B Three Levels Full Treatment Use intubation & ventilation, cardioversion, pacemaker insertion, ICU Limited Additional Interventions Do not use intubation or artificial ventilation, avoid ICU IVs are part of this level Comfort Measures Only Transfer to hospital only if comfort needs cannot be met Sections C, D and E Artificial Nutrition Use long term Use for a defined trial period No artificial nutrition by tube Hospice information (if applicable) Documentation of Discussion Surrogates Signatures Back Page HIPAA compliance Contact information Directions for use Boxes to note changes/review * Box to record the determination that the patient is appropriate * Signature of person completing the form (if not the physician) 9

10 Comfort Measures Always Provided! Each level of care starts with comfort Each successive level includes the previous level Even those receiving full treatment need comfort SUPPORT study majority of dying patients had untreated, but controllable symptoms Recent POLST study higher rate of comfort care with POLST than just DNR Where to Keep the POLST The front of the chart if admitted In a red envelop on the fridge (makes it hard to read when in envelope) Goes with resident (patient) on transfer to another facility Comes back with resident Photocopies stay in medical chart (or EHR) after discharge or in physician s office 10

11 Implementing POLST Establish policies and practices Acceptance of non-staff physician forms Transferring orders Training of all staff Advance care planning practices Training in discussions Review and completion of POLST Updating with clinical changes Integrate POLST in the care plan Policy Questions Should it require: Signature of patient (or surrogate)? Signature of witnesses? Should it be legislatively initiated? Should it be implemented through regulations? More Policy Questions Implementation Hospital and other facility policies on non-staff physician signatures Who manages distribution? Will there be a registry? NPs or PAs sign? 11

12 Future of POLST in FL Legislative route likely needed Some states have used regulations S.B Sen Brandes, St. Pete Physicians and hospitals want immunity for following a POLST in good faith Strong interest in POLST in FL Pilots in Miami (UM), Atlantis (JFK), Tampa (Suncoast), and others Final Thoughts The basis of POLST orders are authentic wishes of the patient Goals and values Advance directives POLST orders The goals of POLST The patient gets what they want Getting what they want means not getting things they don t want POLST Studies Dunn, Schmidt, Carley, et al, A method to communicate patient preferences about medically indicated life sustaining treatment J Am Geriatr Soc 1996;44:785 Tolle, Tilden, Nelson, Dunn, A Prospective study of the efficacy of the POLST J Am Geriatr Soc 1998;46:1097 Lee, Brummel-Smith, Meyer, et al, Physician orders for life-sustaining treatment (POLST): Outcomes in a PACE program J Am Geriatr Soc 2000; 48:1-6 Hickman, Tolle, Brummel-Smith, Carley, Use of the Physician Orders for Life Sustaining Treatment program in Oregon nursing homes: Beyond Resuscitation status. J Am Geriatr Soc 2004; 52:

13 Questions? Center for Innovative Collaboration of Medicine and Law, FSU ration.polst 13