Susan Tolle, MD Director of the Center for Ethics in Health Care Cornelia Hayes Stevens Chair Professor of Medicine in the Division of General Internal Medicine and Geriatrics, OHSU Where we’ve been, where we are & where we’re going

Susan Tolle has no relevant financial relationships to disclose that would present a conflict of interest

POLST P ARADIGM PASTWhy Developed PRESENT Expanding Education Building Sustainable Programs FUTURE New Innovations e-POLST/EMR Registries QA/QI

W HY WAS POLST DEVELOPED ?

ADVANCE DIRECTIVEPOLST For whomFor all adults For persons of any age with advanced illness Purpose To express values and appoint a surrogate (future wishes) Medical orders which turn a patient’s values into action (applies today) Guide treatment decisions in the hospital Yes Guide actions by Emergency Medical Personnel Usually notYes

W HAT FUELED THE SPREAD OF THE POLST P ARADIGM ?

E FFECTIVENESS DATA POLST USE IN SNF /180 NH residents with POLST orders of DNR/comfort measures only received CPR/ICU 5% died in acute care hospital JAGS 46: , 1998

JAGS 58: , 2010 A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physicians Orders for Life-Sustaining Treatment (POLST) Program Susan E. Hickman, PhD, Christine A. Nelson, PhD, RN, Nancy A Perrin, PhD, Alvin H Moss, MD, Bernard J Hammes, PhD, and Susan W. Tolle, MD

POLST USERS WITH C OMFORT M EASURES ONLY 67% less likely to receive life sustaining medical interventions compared to POLST full treatment. S ECTION B P<0.004

C ATEGORIES OF L IFE S USTAINING T REATMENTS JAGS 58: , A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physicians Orders for Life-Sustaining Treatment (POLST) Program Susan E. Hickman, PhD, Christine A. Nelson, PhD, RN, Nancy A Perrin, PhD, Alvin H Moss, MD, Bernard J Hammes, PhD, and Susan W. Tolle, MD

G IVEN AN OPPORTUNITY ONLY 12% OF LONG TERM SKILLED NURSING FACILITY RESIDENTS WANT ICU CARE

2007 POLST LEADERS N EW O RLEANS

Developing Programs National POLST Paradigm Programs Endorsed Programs No Program (Contacts) *As of February 2012

T HE P RESENT A DDRESSING COMMONLY ASKED QUESTIONS Who should have a POLST form? How do advance directives and POLST work together?

H OW A DVANCE D IRECTIVES AND POLST W ORK T OGETHER Adapted with permission from California POLST Education Program © January 2010 Coalition for Compassionate Care of California Age 18 Complete and Advance Directive Update Advance Directive Periodically Diagnosed with Advanced Illness or Frailty(at any age) Complete a POLST Form Change in health status May Complete a new POLST Form Treatment Wishes Honored

W HO SHOULD HAVE A POLST FORM ?

A DDRESSING THE NEED FOR E DUCATION VIDEO

S HARING EXPERIENCE, POLICIES, DATA & EDUCATIONAL MATERIALS

Six core elements of POLST sustainability Leadership Organizational Home Building a sustainable statewide coalition Legislation–Regulatory Mobilizing educational resources Measuring quality performance

L EADERSHIP Succession Planning Depth Commitment Experience Strong Physician Champion(s) Judy Citko

O RGANIZATIONAL H OME Academic health center 501(c)3 advance care planning community based Department of Health State Medical Society Other

O RGANIZATIONAL H OME Collaborative Sponsorship Fit with Mission e.g. industry relationships Coalition Building

B UILDING A S USTAINABLE S TATE - WIDE COALITION Be Inclusive Effective Structure and Communication Regularly Scheduled Meetings

L EGISLATION R EGULATORY Political Capital Relationship with state agencies and other entities EMS structure/relationship

M OBILIZING E DUCATIONAL R ESOURCES Volunteers/sharing resources Infrastructure Communication Networks Secure Financial Support

M EASURING Q UALITY P ERFORMANCE Monitoring Updating Effectiveness Integrating lessons learned

T HE F UTURE OF THE POLST P ARADIGM

D EALING WITH THE ISSUE OF FISCAL IMPACT & THE RHETORIC OF PUBLIC P OLICY

N EW I NNOVATIONS e-POLST Setting national standards for EMR’s

OHSU Epic EHR Snapshot

R EGISTRIES Sharing what we have learned

QA/QI USING DATA TO GUIDE POLST P ARADIGM C HANGE NEW CALIFORNIA DATA January 2012 JAMA

Welcome to the next phase of the National POLST Paradigm Thank you for coming