3/10/2014. This presenter has nothing to disclose

Transcription

1 This presenter has nothing to disclose Understand the elements of an end of life program in outpatient primary and specialty practice Understand the array of tools for end of life conversation in the outpatient setting and skill training set for organizations to offer to patients and providers Be able to articulate a reproducible model to promote end of life care during the routine office visit, or specialty care visit 1

2 Nine sites in Snohomish County, Washington 400 physicians, 500 providers 16 locations Medical, Surgical, Behavioral Health, Urgent Care, Cancer Care, Advanced Care Manager team, Partners in Palliative Care team and hospitalist team Serving 40,000 Medicare patients, have PCP and seen within last 24 months We do what is right for each patient We provide an enriching and supportive work place Our team focuses on value: service, quality, and cost 2

3 Washington State Death with Dignity Act of 2008 Ethics Committee do something about end of life 2011 started patient and physician education 2012 department visits 2013 implemented ACP videos, county wide effort 3

4 Five Wishes Hospice Care EOL Care DNR AD POLST 4

5 55% Yes! No! POLST Savy 20% Yes POLST? POLST 5

6 Conversation with patients None 1 to to 8 > 8 Frequency of conversation, <1 1 to 3 4 to 8 > 8 6

7 Inspire conversation at all levels of care a cultural shift Educate patients and physicians about the options in addition to code/no code/polst and AD: specifically, hospice education, palliative care. Give voice to patients communication of what they value (quality of life) with doctors/care team participating in that conversation as it pertains to goals of care Provide an array of tools to facilitate all of the above HCM Item Video Implementation Interdisciplinary work Patient Education and Provider Education Epic tools, intranet tools, forms utilization and access, naming, vision, goals Conversation 7

8 Physician Survey: Name End of Life Documents chosen: Five Wishes POLST Patient and Physician Education Provider and patient friendly tools Your Life, Your Choices 8

9 Adds the 2012 education class schedule into patient instructions section of AVS Free class helps patients understand their choices at end of life, fill out appropriate forms, and ask questions 17 Talking with our patients about the things we cannot fix. Elizabeth Marshall, MD, MAT, FAAFP Deb Meyers, MD 9

10 Basic and Disease Specific Advance Care Planning A Conversation Based Process MOST IMPORTANT! Health Care Directive / Living Will A Patientdirected Document POLST A Physician s Order 19 7 out of 10 Americans say they would prefer to die at home (Time/CNN Poll 2005) 25% actually die at home (CDC 2005) Patients on hospice live an average of 29 days longer than those receiving aggressive and/or hospital care Patient and loved ones have higher satisfaction with care, lower measurements of stress and anxiety than those in hospital settings Bereavement periods are shorter for those whose loved ones die on hospice 10

11 What is a good death Surveys of patients with terminal illness: avoiding suffering being with family having the touch of others being mentally aware not becoming a burden to others. Decision makers to be named (98%) Want to know what to expect with re their condition (96%) To have finances in order (94%) To say goodbye to important people (90%) To be at peace with God (89%) To resolve unfinished business (86%) To pray (85%) Feel prepared to die (84%) Hope family will be prepared (84%) 11

12 Quality of Life Sudden Death Only 1-2.5% of all deaths in the US 12

13 End of Life Quality of Life Expert Switch Organ failure/age related decline There is nothing more I can DO This is the hero talking for you. 13

14 This is not about the story of the disease; predicting outcomes/statistics/telling the patient what will or won t or might happen. This is about the patient s story- and he/she is the hero/heroine. Stay away from the prognosis! The Surprise Question Would you be surprised if this patient were to die in 12 months? 6 months? 3 months? (Dr. Mimi Patterson) 14

15 The HOPE Questions for a Formal Spiritual Assessment H: Sources of hope, meaning, comfort, strength, peace, love and connection O: Organized religion P: Personal spirituality and practices E: Effects on medical care and end-of-life issues (Am Fam Physician 2001;63:81-8,89.) Grief Giving Voice to Lament Def. intense sorrow Heartache Anguish Angst Pain Woe 15

16 Palliative Care Education Hospice Education and tools Reviewing EPIC tools 16

17 How do you understand your situation? What are your hopes What are your greatest fears? What is most important to you, should you become very sick? I am the medical expert but you are the expert when it comes to what you value, what matters to you. Can we talk about those things? 17

18 Remember: No Code (No CPR) No breathing machine No feeding tube never means No Care And a tool kit for them to walk out with: Hospice Guidelines Go Wish Cards Five Wishes POLST Hospice Information sheets for patients Words that Work 18

19 Internists, FP, Oncology, Pulmonology, Cardiology, Urology, Obstetrics, Neurosurgery, Neurology, Walk In Clinic, ARNP s and PA s Hospice Grand Rounds TEC Sponsored CME Events Upcoming Death with Dignity 19

20 End of Life Symptom Management Faith/Fear/Hope/Regrets Gratitude/Belief Medical Technology Family or tribe or spiritual community Individual or Surrogate decision maker 20

21 Reason, Who, Being Needs Science, What Efficiency Needs Includes links to Engage with Grace, The Conversation Project, Hospice admission guidelines, ordering forms such as Five Wishes and POLST, sobering statistics sheet, Senior Services resources, bereavement resources, Death with Dignity information, etc. 21

22 Tools & Benefit Default filter tab Efficient chart review for end of life related CONVERSATION Life and Wishes class schedule & times for patients Smart text auto populates into AVS patient instructions Hospice screening tool A provider guide to time hospice discussion and or referral Hospice/home care referral consult order Smart text & EPIC order faster than a phone call Hospice Smart text adds a patient instruction hand out describing what hospice is and who qualifies Hospice med panel order Smart text auto populates into the order section.polst Smart text populates a handy tool to document your patients wishes, the FORM is only available in HARD COPY.ADVANCEDIR Smart text populates a summary of discussion ENDOFLIFECONVERSATION Smart text used in progress note ENDOFLIFECAREDISCUSSION Smart set for documentation Sees that provider is paid for time spent on discussion Slide# See Clinical Education intranet page for screen shots 43 Easily locate Conversations Regarding end of Life wishes Find all visits in which any end of life related diagnosis has been entered Used for healthy patient conversation Find link to any visit with POLST or advanced directive added 44 22

23 1 Type hospice in order entry Sign standard med orders for hospice 2 Select referral 45 Within smart text section of patient instructions type hospice Auto-populates a great patient hand out about what hospice is and who qualifies 46 23

24 24

25 General Surgery Sub specialty Behavioral health Oncology All adult primary care Walk In Clinic Annual visits 25

26 100% found the video helpful 100% would recommend it to others 72% said it would change what they think about and choose regarding their care at end of life For those who had an AD already, 77% stated the video changed their plan of care. They tended to move down one step in their care, from more intervention to less. 26

27 Heart disease/chf Cancer Center Dialysis team Pulmonary/Chronic lower respiratory disease (COPD) Neurology/Dementia 27

28 Advance Care Managers and RN staff (they are our best advocates) MA Partners in Palliative Care nursing program We only have ONE social worker! Extended Care/Geriatric Care team Five Wishes Hospice Care EOL Care DNR AD POLST 28

29 POLST AD DNR EOL Care Hospice Care Five Wishes POLST AD DNR EOL Care Hospice Care Five Wishes

30 FP Imed Oncology Others PPC Hospice 30

31 Ideologic separation from palliative care Framing the conversation and providing tools for a variety of providers and circumstances Doctor driven project not from the top down but the bottom up Longevity and visibility within the clinic of the effort s leadership Relationships: a team including EPIC, marketing, administrative support, IT Given relative freedom to create a program with supportive physician leadership POLST vs AD Volandes videos???? Role of ACME team (nurse managers), transitional care team, Partners in Palliative Care team Systematic and measurable vs. organic and education driven: is this an operations issue (standard rooming?) or a compassion driven, art of medicine issue (the latter also ends up being measurable) 31

32 Snohomish Palliative Care Council 2011 Snohomish County Healthcare Leadership Coalition 2012 Targeting EOL care across outpatient, ER, hospital, nursing home and assisted living facilities Focusing on EOL conversation and palliative care education Goals to educate 130 physicians in the county (outside of The Everett Clinic) over 18 months start a program of self sustaining patient education classes through local organizations, such as the YMCA and faith based communities Deepening the Wonder Death is a favor to us, But our scales have lost their balance. The impermanence of the body Should give us great clarity, Deepening the wonder in our senses and eyes Of this mysterious existence we share And are surely just traveling through. 32

33 If I were in the Tavern tonight, Hafiz would call for drinks And as the Master poured, I would be reminded That all I know of life and myself is that We are just a midair flight of golden wine Between His Pitcher and His Cup. If I were in the Tavern tonight, I would buy freely for everyone in this world Because our marriage with the Cruel Beauty Of time and space cannot endure very long. Death is a favor to us, But our minds have lost their balance. The miraculous existence and impermanence of Form Always makes the illumined ones Laugh and sing. Hafiz, 14th Century Persian poet and mystic 33