Making Tough Conversations Less Difficult: Helping Patients & Families with Advanced Care Planning Adele W. Pike RN, EdD Visiting Nurse Association of Boston and Affiliates Christine McCluskey RN, MPH Commonwealth Medicine, UMASS Medical School Jane Pike-Benton RN, MS HomeHealth & Care Transitions MetroWest HomeCare & Hospice

Wednesdays At the Movies An educational series to help home care clinicians engage patients and families in discussions about their goals of care, care options, and advanced care planning

“I never want to go back into the hospital again.”

Video Clips  The Shootist  Terms of Endearment  Little Miss Sunshine  Wit  Tuesdays with Morrie  Steel Magnolias  Young At Heart  Bill Moyer’s How We Die  PBS Caring for Parents  PBS Living Old

Mother and Daughter in Providence (video clip) WGBH Educational Foundation (2008). Caring for Your Parents

What we found: Muriel Gillick’s framework for talking with patients about goals of care really worked for our clinicians Advanced Care planning is an ongoing discussion, not a one time event How much each of us imposed our own goals on a patient’s situation instead of listening for the patient’s goals Our clinicians were not aware of all the resources Hospice offered, including consultation around symptom management and joint visits There is a need for more community based palliative care resources

Muriel Gillick’s Framework Longevity Comfort Function Gillick, M.R. (2001). Choosing Appropriate Medical Care for the Elderly. Journal of the American Medical Directors Association. 2(6),

Changes in Practice Among our Clinicians:

For more information about Wednesdays at the Movies... Contact :

A process for discussing, documenting, communicating & honoring patient preferences for life-sustaining treatments A standardized form for writing & communicating medical orders for life-sustaining treatments A portable document that travels with the patient & is honored by health care professionals across care settings Voluntary for patients of any age who are nearing the end of life 10

Key facts about MOLST in MA 11 Part of advance care planning, but not an advance directive, and it takes effect immediately on completing form Is an implementation tool for advance care planning conversations applied to current medical decision making Represents the standard of care for documentation of patient and clinician discussions with the resulting medical orders Can be used to refuse or accept life sustaining treatments

MOLST Form Page 1: ◦ Medical Orders for Life Sustaining Treatments ◦ DNR, DNI, DNH Page 2: ◦ Statement of Patient Preferences for Other Medically Indicated Treatments 12

Increasing Conversations between clinicians and patients about patient prognoses, values & goals of care; Patient understanding about medically-indicated treatments; Documentation of patient treatment preferences ; Communication of preferences across treatment sites; and Decreasing The use of treatments that the patient does not want. MOLST Goal: to improve patient-centered care by 13

MOLST and the Health Care Proxy MOLST does not replace the need for all adults (age 18 & older) to complete a Health Care Proxy form to appoint a health care agent. A health care agent is the person authorized to make health care decisions on one’s behalf in the future if one loses capacity to make health care decisions. A MOLST form contains medical orders based on a patient’s own preferences. It is suitable for very sick patients nearing the end of life & goes into effect as soon as it is signed. 14

Transitions of Care & MOLST Transitions of Care & MOLST HOSPITALREHAB NURSING HOME HOMEOUTPATIENT MOLST 15

MOLST Statewide Expansion Principles 1. Strategic Collaboration Collaborate with statewide, cross-continuum initiatives already underway in MA Don’t “re-invent the wheel” 2. Capacity Expand MOLST first in organizations that have both interest in MOLST & capacity to implement MOLST Expand MOLST to other health care organizations & institutions in the Worcester area 16

For more information go to

Provide the right care for each patient at the right time in the right care setting Transitions in Care: Caring for our Patients Connecting our Partners Transitions in Care: Caring for our Patients Connecting our Partners

Multi-disciplinary approach to shift the culture of our acute care facilities regarding serious illness and end of life care Palliative Care Program - Mission

 Fall 2009  STAAR Team record review of readmitted HF patients reveals multiple patients with chronic HF and end of life concerns. Our Journey  May 2010  MetroWest Medical Center Ethics Committee ask MetroWest HomeCare & Hospice to collaborate to develop an Inpatient Palliative Care Program  August 2010  Saint Vincent Hospital and MetroWest HomeCare & Hospice team up to create a cross-continuum Inpatient Palliative Care Program

Feb 2011  Inpatient Palliative Care Program begins consults at MWMC Our Journey April 2011 o Inpatient Palliative Care Program begins consults at SVH

Palliative Care Steering Committee  approves policies & procedures, physician order sets and drives the cultural shift through education Palliative Care Consult Team  meets with patients, family members and health care team members to discuss patient wishes and options Palliative Care Program Structure

Important to align the Palliative Care Program with the Ethics Committee, Cancer Care Center, Intensive Care, Emergency Department, Physicians, Hospitalists, Nursing and Chaplaincy, as well as other care team members Palliative Care Program Structure

Additional Responsibilities o Policies and Procedures o Physician Order Set o Education at Physician, Nursing and Administrative Meetings o Schwartz Rounds o Palliative Care Informational Fairs

RESOURCES Introduced in 1997 with funding from a grant from the Robert Wood Johnson Foundation Changes the way we talk about and plan for care at the end of life Simple to use Available in 15 languages Can also be completed on line

 Enhance pain and symptom management  Care concordant with patient-family preferences  Improved patient and family satisfaction  Reduced costs via shorter length of stay, decreased readmissions and less acute treatment ordering  Earlier transition of care to Bridge or Hospice care Hospital – Hospice Partnerships in Palliative Care Benefits as per NHPCO

 Patients who are discharged savings- $1696  Patients who die in the hospital savings - $4900  Decreased readmission rate of patients with chronic and/or end of life illness Morrison et al published an article in The Archives of Internal Medicine 2008;168(16): “Cost Savings Associated with US Hospital Palliative Care Consultation Programs” Other Potential Benefits

Palliative Care Outcomes 169 consults completed in the first 7 months 169 consults completed in the first 7 months Many patients with chronic illness unrelated to cancer 37% of patients were admitted from Skilled Nursing Facilities

It’s about how you live

Center for Advancement of Palliative Care Resource for tools, articles, templates for policies and procedures Center for Advancement of Palliative Care Resource for tools, articles, templates for policies and procedures Resources Five Wishes Five Wishes NHPCO-National Hospice & Palliative Care Organization NHPCO-National Hospice & Palliative Care Organization

31 Discussion & Reflection