Slide 1

Slide 2

A Primer for Home Health Clinicians

Slide 3

Advance Care Planning: The Role in Population Health Management Population Health Management is focused on managing patients with chronic illness in a more proactive, anticipatory manner. Most chronic illnesses have a predictable trajectory. How do we prepare patients in a more responsible and sensitive manner to the path that their illness will most likely take? How can we as home care providers: a. Engage patients in conversations about their disease pathway? b. Enpower patients to participate in their careplanning process?

Slide 4

Could This Happen In Roanoke? Mr. Dehart, a 71 year old patient with severe COPD and mild dementia, resides at home with his wife. He develops increasing SOB and his wife calls 911. When EMS arrives, the adult daughter, visiting from out of town, advises them the family wants everything done. The wife does not mention her husbands DDNR. EMS staff, having found the patient unresponsive, try to intubate him, but cannot. They insert an oral airway and transport the patient to the ER. Mr. Dehart remains unresponsive with a RR of 8 and an O 2 sat of 85% despite supplemental O 2. Pursuant to a chest X- ray, the ER physician writes, full code for now, status unclear. The staff intubate Mr. Dehart and transfer him to the intensive care unit.

Slide 5

What Went Wrong?

Slide 6

DDNR order not communicated to EMS and in subsequent transfer. Advance directive not documented. (Do you think advance directive would have been followed in this situation if it were documented?) Family at odds with patients wishes. Lack of communication between healthcare providers treating clinicians left out of loop. Results include overtreatment of patient with unnecessary physical discomfort, costs, and prolonged dying process.

Slide 7

The problem with communication is the illusion that it has been accomplished. - George Bernard Shaw

Slide 8

Common Issues With Advance Directives Advance Directives (AD) frequently use statutory language that can be hard to understand. Healthcare staff trying to assist patients in completing an AD often focus on how to complete the form, not adequately discussing the issues at hand. Focus has been more on legal rights and less on help for patient in making informed decision about his/her individual care.

Slide 9

Story of Stephanie Martin Glennon January 2013 Stephanies husband, a physician and internist was diagnosed with metastatic pancreatic cancer. No one but my husband and I seemed to want to talk about [that care]. With unwavering support of friends, we were able to get my husband home only by going rogue [when a] medical director was resistant to sending him home, and was suggesting yet more procedures he did not want and could not endure. We took him home, where he was surrounded by us and friends and other family members, surrounded by our childrens artwork and pictures and music and where, for the first time during this ordeal, he encountered no pain and no nausea and finally was in comfort. He was able to speak and laugh and reminisce until he slipped into unconsciousness on his very last day and died peacefully, without medical interventions he never wanted.

Slide 10

What is POST? A physician order Can be completed by a non-physician provider such as an NP or PA as well an MD or DO (Osteopath) Complements, but does not replace, advance directives Voluntary use Recognized by EMS as a valid DDNR 9

Slide 11

Who Is Eligible For POST? 1. Seriously ill persons, i.e., those with chronic, progressive disease 2. Terminally ill persons

Slide 12

Conversations that change over time Source: Carol Wilson, Riverside Health System; Used with permission Healthy Adults: Emergency Planning People with Progressive Illness: guided planning End Stage Illness: Physician Orders for Scope of Treatment

Slide 13

Who Is Eligible For POST? Prompt for POST completion: Would I be surprised if this patient died in the next year?

Slide 14

Living Will vs. POST (Remember: Patients may have both forms.) Living Will* For every adult regardless of health Decisions about open- ended myriad of treatments Needs to be retrieved Normally requires interpretation (*Hastings Center Report 2004; 34: 30 42) POST For seriously or terminally ill adults Decisions among presented treatment options Stays with patient Physicians order for specific treatment(s)

Slide 15

Purpose of POST To provide a mechanism to communicate patients preferences for end-of-life treatment across treatment settings To improve implementation of advance care planning 14

Slide 16

Expected Outcomes of Using POST Process Improved continuity of careForm transferable across treatment settings Clearer communication of wishes Reduced hospitalization and inappropriate life- sustaining treatments Fewer EMS transports More accurate representation of preferences Higher adherence to wishes by medical professionals.

Slide 17

POST Can Be Completed In Many Settings

Slide 18

The Conversation POST discussions must be facilitated by the patients physician or a trained Advance Care Planning Facilitator (ACPF). The facilitator may choose to involve other members of the patients healthcare team as well. The dialogue may or may not result in the completion of a POST document, but it does create an environment of shared and informed decision making for the patient facing serious illness.

Slide 19

Role of ACP Facilitator 1. Explores patients understanding of advance care planning and the role of a healthcare representative. 2. Explores understanding of medical condition, including possible complications that may occur. 3. Provides meaningful context for decision making through identifying previous key healthcare experiences, fears & worries, values, and important beliefs. 4. Explores patients understanding of CPR, comfort care, antibiotics, artificial nutrition and hydration, etc. 5. Ensures that patients wishes are clearly documented on transferable form. 6. Develops list of pertinent questions that may involve physician and others.

Slide 20

Why an Advance Care Planning Facilitator (ACPF)?

Slide 21

Why an ACPF? Has received training in having discussions with patients and POAs about preferences for EOL care Training was based on our POST form The Advance Care Planning process takes about 45 minutes and often involves follow-up and/or additional sessions It is important that POST form is not just a check off sheet---an ACPF can make sure people know and understand their options

Slide 22

Who in our family are ACPs? Megan Moore, Hospice Social Worker Roanoke Debbie Quick-Conner, Hospice Social Worker Roanoke Nicole Bailey, Home Health Social Worker Tina Smusz, Hospice Medical Director Lisa Sprinkel, Home Care and Hospice Leigh Faulconer, Hospice Social Worker NRV Sharon Crane, Hospice Social Worker NRV

Slide 23

How to Complete a POST Form Must be completed by a physician or by a non- physician health care professional who has been trained as a POST Advance Care Planning Facilitator (ACPF). Must be based on patient/resident preferences Must be signed by an MD or DO Next form revision (in mid 2013)NPs and PAs will be able to sign

Slide 24

POST Form

Slide 25

24

Slide 26

25

Slide 27

Section A: Resuscitation Only section applicable to EMS These orders only apply if a person is pulseless and apneic. This section does not apply to any other medical circumstances. POST recognized as a valid Virginia Other DNR When Do Not Attempt Resuscitation is checked, qualified healthcare personnel are authorized to honor this order as if it were a Durable DNR order OEMS approval (Michael Berg) If a patient is in a qualified health care facility such as a nursing home or home on routine hospice care, a Durable DNR AND POST form is not needed. The POST form is preferred due to its comprehensive nature. 26

Slide 28

Section B Person Has Pulse and/or is breathing - Comfort Measures -Limited Additional Interventions -Full Interventions All care above plus intubation and cardioversion Note re: antibiotics: Antibiotics are often life-sustaining treatments, so advance care planning can help clarify goals of care in order to make the best decision. It may be helpful to explain other treatments such as antipyretics and opioids to treat symptoms of infection and maintain comfort. 27

Slide 29

Section C: Artificial Nutrition Can be emotionally laden discussions. Emphasize the medical nature of this decision. Explain the medical, legal and ethical justification that artificially administered nutrition is a medical intervention that can be accepted or declined based upon the patients goals, values and priorities. Surrogate decision makers can consent or decline the intervention based upon their substitute judgment for the patient. Address any and all fears of neglect and abandonment. 28

Slide 30

Signatures 29

Slide 31

Back Side of Form Signature of the health care professional preparing the form. Directions for Health Care Professionals 30

Slide 32

Location And Transfer Of POST Form

Slide 33

Location Of The POST Form It is best if the original POST form (canary yellow color) accompanies the patient when transferred or discharged. A copy is acceptable, however, if the original document is not available. The POST form is transferred in a large red envelope, which stays with the original document (see next slide). In Hospital or Nursing Facility: Will be kept in the very front of patients chart. In Patients Private Residence: should be kept on refrigerator door, either in red envelope or with easy access to red envelope.

Slide 34

The Red Envelope for Transfer/Discharge

Slide 35

Envelope Label ORIGINAL POST/DDNR Form Enclosed Form is to accompany Patient upon Discharge/Transfer PLEASE RETURN ORIGINAL FORM IN THIS ENVELOPE TO: (Patient Name) (Address)

Slide 36

Transfer Of POST With Patient Red envelope with original POST should be placed on top of transport papers. The healthcare facility initiating the transfer shall communicate the existence of the POST form to the receiving facility prior to the transfer. The POST form shall accompany the person to the receiving facility and shall remain in effect.

Slide 37

Modifying POST Decisions

Slide 38

To Review, Change, or Void POST Review of Form is required when: 1. The patients preferences change 2. Patient is transferred from one healthcare setting to another setting, including admission to hospice care. 3. Patient has significant change in health.

Slide 39

To Review, Change, or Void POST Patient should always be involved in review process, as well as his/her representative. An ACP Facilitator and/or patient physician/NP/PA is preferred to lead review process. When patient is new to our service, but already has a POST form in place, the review should be coordinated.

Slide 40

To Review, Change, or Void POST There are 3 possible review outcomes: NO CHANGE FORM VOIDED, new form completed Complete a new form indicating the patients current wishes After doing so, write the word VOID in large letters across the both the front and back of the original POST form, and include the date the form was voided. Keep the original in the patients medical record to be archived according to agency policy. The new form will be kept with the patient if living at home or in front of the facilitys chart where her or she is located. FORM VOIDED, no new form

Slide 41

When Not To Complete A POST Form A POST form should not be completed if the patient requests contradictory orders. One of the most likely examples: the patient wants CPR in Section A, but wants only limited additional interventions in Section B. The performance of CPR requires full treatment. If the patient does not want full treatment, including intubation and mechanical ventilation in an ICU, then the patient should not receive CPR.

Slide 42

Slide 43

Take-Home Messages POST provides a better means than AD to identify and respect patients wishes POST completion will improve end-of-life care throughout the system Use of POST will require communication to make it work in your community Know your role. Wheres the POST form? 42

Slide 44

POST Resources Palliative Care Partnership of the Roanoke Valley www.pcprv.org Contact Person for POST: Laura Pole, lpchef@earthlink.net lpchef@earthlink.net Virginia POST Collaborative www.virginiapost.org Respecting Choices www.respectingchoices.org See list of attached area professionals who are certified as Trainers and/or Facilitators in Advance Care Planning