Matthew Kestenbaum, MD Virginia POST Collaborative Medical Director, Health Information & Training Capital Caring based on a presentation by Laura Pole, RN, MSN, OCNS and Chris Pile, MD Virginia POST Collaborative and Palliative Care Partnership of the Roanoke Valley

 One version of “POLST Paradigm Programs” ◦ Physician’s Orders for Life Sustaining Treatment  A physician order set  Transfers across care settings  Can be completed by any provider or a trained Facilitator but must be signed by qualified MD, DO, NP or PA  Complements, but does not replace, advance directives 3

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Developing Programs National POLST Paradigm Programs Endorsed Programs No Program (Contacts) *As of February

Developing Programs National POLST Paradigm Programs Endorsed Programs No Program (Contacts) *As of February The Virginia POST Executive Committee is in the process of submitting the “Endorsed Programs Application”

IDEA +1 Local Pilot ProjectState Stakeholders Grant & In-Kind Support + = Virginia POST Collaborative & 13 Regional POST Programs History of POST in Virginia Palliative Care Partnership of the Roanoke Valley

POST is designed to honor the freedom of persons with advanced illness to choose their preferred types of treatment across settings of care POST is Entirely Voluntary: – No one has to complete a POST Choice to have or to limit treatments The patient may revoke or change at any time Comfort measures are always provided 9

 Patients with a chronic, progressive illness  Patients with a recognized terminal illness  Such patients who have or establish an advance directive or living will can (and often should) also complete a POST form 10

 For every adult  Requires decisions about myriad of future treatments  Requires interpretation  Needs to be retrieved  For the seriously ill  Decisions among presented options  Medical orders which turn a patient’s values into action  Follows patient across settings of care on consistent document *Fagerlin & Schneider. Enough: The Failure of the Living Will. Hastings Center Report 2004;34:30-42.

12  The “surprise” question ◦ Would you be surprised if this person died in the next year?  If the answer is “no” (you wouldn’t be surprised), then a POST form may be the best documentation of the patient’s informed choices for medical treatment.  Flacker Mortality Scale ◦ Based on MDS Data  Local Coverage Determination (LCD) for Hospice ◦ Can help predict a prognosis of <6 months

 No specific end of life care orders means patients want full interventions. ◦ Maybe, maybe not... ◦ And what’s the default if the patient can’t tell you?  A DNR order means a patient doesn’t want more than comfort measures.

 DNR Status is not a predictor of the care patients wish for at the end of life—many with DNR chose limited or full interventions as well as artificial nutrition.  PO(L)ST is a neutral form—allows patients to have or limit treatment.  PO(L)ST reduces making assumptions based on DNR status alone. Fromme, E.K. Zive, D., Schmidt, T.A., Olszewski, E. & Tolle, S.W. POLST Registry, Do- Not-Resuscitate orders and other patient treatment preferences. Journal of the American Medical Association (1):

The POST Form Current Form: Front

The POST Form Current Form: Back

18 Revised Form: Front Summer 2013 Release is planned The POST Form

19 Revised Form: Back Summer 2013 Release is planned The POST Form

20 The POST Form: The part which is most important to you

DDNRFactSheet.pdf (last accessed July 26, 2013).

○ “Other” DNR Orders: this is the term used to define a physician’s written DNR order when it is in a format other than the State form. “Other” DNR Orders should be honored by EMS providers’ when the patient is within a license health care facility, being transported between health care facilities, or receiving hospice or health care services at home. Examples of “Other” DNR orders include facility developed DNR forms, POST forms, or other documents that contain the equivalent information as the State form.

It is well established that there are significant deficits in the current system of care transitions, but there is limited evidence as to which interventions will most positively affect outcomes. We welcome additional data and new models of care that will help us create and evolve optimal processes for transitions between care settings. In the meantime, we propose some basic tenets that we believe, at least intuitively, will serve as underpinnings to enhance safe and efficient transitions: Consistent discussion and documentation of advance directives and end-of-life care preferences, with up-to-date POLST (Physician Orders for Life Sustaining Treatment)/POST (Physician Orders for Scope of Treatment)/MOLST (Medical Orders for Life Sustaining Treatment)/MOST (Medical Orders for Scope of Treatment) forms or, in states where these are not available, with other appropriately executed advance directive forms. *

 The Respecting Choices Advance Care Planning Facilitator Program has been chosen as our training model in Virginia ◦ Respecting Choices is owned and operated by Gundersen Health System, a not-for-profit 501(c)(3) corporation located in La Crosse, WI.Gundersen Health System  Fundraising from state and regional funding sources (including GTE) for training process.  Pre-workshop online learning modules + all-day workshop.  15 training sessions with nearly 450 facilitators trained from multiple disciplines thus far

 As of August 2013 ◦ Leewood Healthcare Center  7120 Braddock Rd., Annandale, VA  Facilities planning on implementing POST in the near future ◦ The Jefferson (Sunrise Senior Living)  900 North Taylor St., Arlington, VA 22203

 We are close to the tipping point ◦ Capital Caring: Large hospice and palliative medicine provider with over 1,100 hospice patients per day ◦ Inova Health System now has an system- wide Director of Palliative Care who is supportive of the POST Program  Jessica Heintz, MD ◦ Sentara Healthcare has implemented the POST form in other regions of the state and is now focusing on Northern VA  Amanda Becker, LCSW

 We are close to the tipping point ◦ Capital Caring, Inova Health System, and Sentara Healthcare are jointly organizing an informational meeting for all interested healthcare facilities and organizations ◦ Tentatively planned for October 2013 ◦ Potential Advance Care Facilitator Training in December 2013

 Began in December 2009  Most ACP discussions and POST forms were done in nursing care facilities  QI data collected from medical records of nearly 100 residents/patients with POST forms: ◦ 98% congruency between orders written and care delivered

 9 transfers ◦ 1 to ALF ◦ 4 to ED (2 for foley insertion, 1 for GI bleed; other unknown) ◦ 2 admitted to hospital (1 died in hospital, other returned to facility) ◦ 2 transferred to VAMC Palliative Care unit.

 Residents who died with a POST form: ◦ Only 1 patient died in an acute care unit ◦ Desired outcome?  Residents who died without POST form: ◦ 25 % died in acute care setting in hospital  Implications to hospitals/facilities for readmission scrutiny

 For a full listing of POLST research, go to: resources/quality-improvement/ "Click on “POLST Paradigm Lit Review”  See handout copy of article by Pile and Pole in Age in Action Quarterly 35

 POST provides a better means than AD alone to identify and respect patients’ wishes  POST completion will improve end-of-life care throughout the system  Use of POST requires communication to make it work in our community  Local, Regional and Statewide collaboration is pivotal to making POST available as a uniform, portable and legal document and process

 National POLST Paradigm:  Virginia POST Collaborative: National Hospice Foundation: National Hospice and Palliative Care Organization: Palliative Care Partnership of the Roanoke Valley: “Hard Choices for Loving People” by Hank Dunn

 Virginia POST Collaborative: Chris Pile Laura Pole Matt Kestenbaum   38

RegionContact CharlottesvilleLois Eastern Virginia Peninsulas Carol Eastern Virginia Southside David Fairfax/NOVAMatthew Kestenbaum FredericksburgRebecca Harrisonburg/Rocking- ham County Cindy LynchburgPatricia New River ValleyKarolyn Rapidan/Rappahannack Region Chris RichmondKen RoanokeLaura WinchesterLynn 39