1. Chris Pile, MD Medical Director Virginia POST Collaborative Sue Ranson, MSN Chair Palliative Care Partnership of Roanoke Valley

2. “Death is an inevitable aspect of the human condition. Dying badly is not.” Jennings, et al, 2003

3.  Need for more specific advance care planning at the end of life.  The process of making POST available as a communication tool for end of life care wishes.  How POST is affecting end of life care at the bedside.  Resources

5. An Index Case Mr. Jan

6.  Advance directives not documented  DNR order not communicated in transfer  Fragmentation in care (2 hospitals)  Overtreatment against patient’s wishes  Unnecessary pain and suffering  System-wide failure to respect pt’s wishes  Failure to plan ahead for contingencies  No system for transfer of plan

7. Living Wills Have Failed  25% of adults have ADs  50% of people with advanced illness  Completed without guidance  Not applicable until patients are “terminal”  Focused on a menu of choices rather than desired (and reasonable) outcomes  In one study, families accurately stated what was important to their loved one who had a terminal illness only 50% of the time.*  Depression and Impact of Event scores were significantly lower for bereaved families when they had participated in Advance Care Planning.** *Engleberg, R., Patrick, D. & Curtis, J.R. (2005) ** Journal of Pain & Symptom Management March 2007 7

8. Century of Change* 19002008 Average age of death 47 years of age78 years of age Causes of death Infection 34% Heart Disease 25% Heart Disease 9% Cancer 23% CVA 7% COPD 6% Accidents 5% CVA 5% Time of disability before death Days, weeks2 Years average *2008 CDC statistics 8

9. Chronic Disease with Exacerbations 9

10. Evolving Realities  Increased prevalence of chronic disease  Increased comorbidities and frailty with medical advances adding to complexity  People receive care: They do not want From which they cannot benefit  People fail to receive care: They do want From which they will benefit  Death is “optional” 10

12. What is POST?  POLST Paradigm  A physician order set  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 12

13. Components of the POLST Paradigm  Standardized practices and policies  Trained advance care planning facilitators  Timely discussions prompted by prognosis  End-User training for Providers and EMT  Clear, specific language on an actionable form  Bright form easily found among paperwork  Orders honored throughout the system  QI activities for continual refinement 13

15. Healthy Adults: Emergency Planning People with Progressive Illness: guided planning End Stage Illness: Physician Orders for Scope of Treatment

16.  Name a Healthcare Agent  Prepare for sudden injury or event  Complete basic Advance Directive Source: Carol Wilson, Riverside Health System; Used with permission

17.  Understand potential complications and treatment options  Consider benefits and burdens of end of life treatments  Discuss preferences with family  Make Advance Directive more specific  Re-evaluate goals with changes in condition Source: Carol Wilson, Riverside Health System; Used with permission

18.  No longer hypothetical  Express preferences for treatment as medical orders  Use POST form in communities where it is accepted Source: Carol Wilson, Riverside Health System; Used with permission

19.  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.

20.  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.

21.  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. (2012). POLST Registry, Do-Not-Resuscitate orders and other patient treatment preferences. Journal of the American Medical Association, 307(1), 34-35.

23. 2007200820092010201120122013 History of POST in Virginia IDEA +1 Local Pilot ProjectState Stakeholders Grant & In-Kind Support + = Virginia POST Collaborative & 13 Regional POST Programs

24. Developing Programs National POLST Paradigm Programs Endorsed Programs No Program (Contacts) *As of February 2013 24

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30.  Clear Message: Who is appropriate for POST?  Becoming a participating pilot project region.  Advance Care Planning Facilitator Training  PCP Training  End-User Training  Public Education

31.  POST is for:  Seriously ill patients*  Terminally ill patients  Those with advanced frailty  Gives options to limit or have care  Voluntary  Can be revoked or changed  Comfort measures always offered * chronic, progressive disease/s

32.  Careful discussions that elicit care preferences ARE the main thing.  Who will facilitate these discussions ? ◦ Non-physician POST ACPF’s must be certified in order to have conversation and assist in POST form completion

33.  Designated ACPF training model for Virginia  Fundraising from state and regional funding sources (including GTE) for training process.  Pre-workshop online learning modules + all-day workshop.  17 training sessions with nearly 500 facilitators trained from multiple disciplines

34.  Problem: Few physicians have time to participate in RC Training  GTE Grant: Develop, pilot and refine a one- hour training for physicians caring for POST- appropriate patients.  Theme: Promote It, Sign It, Honor It  CME credits granted

35.  For care providers who are likely to come in contact with a patient with a POST form.  Participating hospitals, nursing care facilities, hospices, EMS, and other care settings.  GTE Funding to refine template presentations in multiple formats: ◦ Live presentations ◦ Online self-paced module  Thousands of end-users trained in pilot regions.

36.  Primarily limited to pilot project regions.  Growing interest and multiple requests from patients/families  Virginia POST Website: ◦ Funding from National POLST, GTE and a hospital system. ◦ Full website up and running by Summer 2013

37. Roanoke Valley Pilot Project QI Study

38.  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

39.  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.  Place of Death: Only 1 patient with a POST form died in an acute care unit in the hospital  Residents who died without POST form: 25 % died in acute care setting in hospital  Implications to hospitals/facilities for readmission scrutiny

40.  PO(L)ST is achieving its goal of honoring tx preferences of those with advanced illness or frailty.  Plus----PO(L)ST serves as an ACP conversation catalyst”

41. Bringing POST to LGMC  Identifying key stakeholders  Select champions from administrative and clinical areas  Devote Resources  Implementation: ◦ Developing Policies and Procedures ◦ Education and Training across the system ◦ Go-live ◦ QI

42.  National POLST Paradigm: www.polst.orgwww.polst.org  Virginia POST Collaborative: www.virginiapost.org National Hospice Foundation: www.hospiceinfo.org National Hospice and Palliative Care Organization: www.nhpco.org Palliative Care Partnership of the Roanoke Valley: www.pcprv.orgwww.pcprv.org “Hard Choices for Loving People” by Hank Dunn

43.  National POLST Paradigm: www.polst.org  VHHA: http://www.vhha.com/healthcaredecisionmaking. html  NHPCO: Caring Connections: http://www.caringinfo.org  National Health Care Decisions Day: http://www.nhdd.org/

44.  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 your community  Local, Regional and Statewide collaboration is pivotal to making POST available as a uniform, portable and legal document and process.