Physician Orders For Scope Of Treatment: The Roanoke Pilot Project for POST

Physician Orders For Scope Of TreatmentA Primer for Home Health Clinicians1Advance Care Planning: The Role in Population Health ManagementPopulation 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?

2Could 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 O2 sat of 85% despite supplemental O2. 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. 3What Went Wrong?

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What Went Wrong?

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.

5 The problem with communication is the illusion that it has been accomplished.

- George Bernard Shaw6Common Issues With Advance DirectivesAdvance 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.7Story of Stephanie Martin GlennonJanuary 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.What is POST?A physician orderCan 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 useRecognized by EMS as a valid DDNR

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9Who Is Eligible For POST? Seriously ill persons, i.e., those with chronic, progressive diseaseTerminally ill persons

10 Conversations that change over time

Source: Carol Wilson, Riverside Health System; Used with permissionWho Is Eligible For POST? Prompt for POST completion:

Would I be surprised if this patient died in the next year?

12Living Will vs. POST (Remember: Patients may have both forms.)Living Will*For every adult regardless of healthDecisions about open-ended myriad of treatmentsNeeds to be retrieved Normally requires interpretation

(*Hastings Center Report 2004; 34: 30 42)

POSTFor seriously or terminally ill adultsDecisions among presented treatment optionsStays with patientPhysicians order for specific treatment(s)

13Purpose of POSTTo provide a mechanism to communicate patients preferences for end-of-life treatment across treatment settingsTo improve implementation of advance care planning14

14Expected Outcomes of Using POST ProcessImproved continuity of careForm transferable across treatment settingsClearer communication of wishesReduced hospitalization and inappropriate life-sustaining treatmentsFewer EMS transportsMore accurate representation of preferencesHigher adherence to wishes by medical professionals.

15POST Can Be Completed In Many Settings

The ConversationPOST 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.

17Role of ACP FacilitatorExplores patients understanding of advance care planning and the role of a healthcare representative.Explores understanding of medical condition, including possible complications that may occur.Provides meaningful context for decision making through identifying previous key healthcare experiences, fears & worries, values, and important beliefs.Explores patients understanding of CPR, comfort care, antibiotics, artificial nutrition and hydration, etc.Ensures that patients wishes are clearly documented on transferable form.Develops list of pertinent questions that may involve physician and others.

18Why an Advance Care Planning Facilitator (ACPF)?

Why an ACPF?Has received training in having discussions with patients and POAs about preferences for EOL careTraining was based on our POST formThe Advance Care Planning process takes about 45 minutes and often involves follow-up and/or additional sessionsIt is important that POST form is not just a check off sheet---an ACPF can make sure people know and understand their optionsWho in our family are ACPs?Megan Moore, Hospice Social Worker RoanokeDebbie Quick-Conner, Hospice Social Worker RoanokeNicole Bailey, Home Health Social WorkerTina Smusz, Hospice Medical DirectorLisa Sprinkel, Home Care and HospiceLeigh Faulconer, Hospice Social Worker NRVSharon Crane, Hospice Social Worker NRV

How to Complete a POST FormMust 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 preferencesMust be signed by an MD or DONext form revision (in mid 2013)NPs and PAs will be able to sign

POST Form23

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Section A: ResuscitationOnly section applicable to EMSThese 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 orderOEMS 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

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Section B

Person Has Pulse and/or is breathing-Comfort Measures-Limited Additional Interventions-Full Interventions All care above plus intubation and cardioversionNote 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.

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27Section C: Artificial NutritionCan 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

28Signatures29

29Back Side of FormSignature of the health care professional preparing the form.Directions for Health Care Professionals 30

30Location And Transfer Of POST FormPOST31Location Of The POST FormIt 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.

32 The Red Envelope for Transfer/Discharge

33Envelope LabelORIGINALPOST/DDNRForm Enclosed

Form is to accompany Patient upon

Discharge/Transfer

PLEASE RETURN ORIGINAL FORM IN THIS ENVELOPE TO:

(Patient Name)(Address)34Transfer Of POST With PatientRed 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.

35Modifying POST Decisions

36To Review, Change, or Void POSTReview of Form is required when:The patients preferences changePatient is transferred from one healthcare setting to another setting, including admission to hospice care.Patient has significant change in health.

37To Review, Change, or Void POSTPatient 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.

38To Review, Change, or Void POSTThere 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

39When Not To Complete A POST FormA 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.

40Questions???

41Take-Home MessagesPOST provides a better means than AD to identify and respect patients wishesPOST completion will improve end-of-life care throughout the systemUse of POST will require communication to make it work in your communityKnow your role.Wheres the POST form?42

42POST ResourcesPalliative Care Partnership of the Roanoke Valleywww.pcprv.orgContact Person for POST: Laura Pole, lpchef@earthlink.netVirginia POST Collaborativewww.virginiapost.orgRespecting Choiceswww.respectingchoices.orgSee list of attached area professionals who are certified as Trainers and/or Facilitators in Advance Care Planning

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