Post -a better means for communicating end of life care wishes


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  • Perhaps the most revealing data on the POLST Paradigm were presented at the 2012 National POLST Conference. Data from Oregon assuage the unfounded concern of some that the PO(L)ST form is biased toward steering patients to limit care. Researchers, analyzing all active forms signed and submitted from December 2009 through December 2010, investigated the populations using the POLST registry and their preferences for treatment, and determined the prevalence of each POLST order. The researchers then calculated the probability of other specific end-of-life care orders, depending on whether patients had a DNR order or an attempt CPR order. There was significant heterogeneity in orders, meaning that many patients, including those who did not want to be resuscitated, chose to have additional limited or full interventions and/or tube feedings. Clearly, the POLST form is a neutral form and meets the intent of honoring the freedom of persons with advanced illness or frailty to have or limit treatment. Another critical implication of these results is that a DNR order alone is a poor predictor of the medical care that dying patients want. It is not uncommon for health care professionals to assume that patients who do not want to be resuscitated would choose to have only comfort measures
  • Mrs. West was a 92 year-old widow who lived on a long-term care unit at a large nursing care facility in Virginia. She had chronic renal disease, heart failure, diabetes, hypertension, and a recent stroke. Her heart failure and renal disease were progressing, making it clear that she was not likely to live more than a year. A social worker at this facility, trained as a POST Advance Care Planning Facilitator, informed Mrs. West and her daughter that they could avail themselves of a process of advance care planning that would result in a doctor’s order sheet that would serve as a communication tool both within and outside the facility. The daughter, who had Mrs. West’s medical power of attorney, was particularly interested because her brother tended to press their mother to have more interventions than Mrs. West wished. In the POST Advance Care Planning session, Mrs. West said she did not want to be resuscitated when she stopped breathing and her heart stopped beating. She added that, in addition to aggressive comfort measures, she wanted some limited medical interventions, such as cardiac monitoring, less invasive airway support, and transfer to the hospital, if indicated, but asked that health care providers avoid putting her in the ICU. Mrs. West’s primary care physician reviewed the POST orders with Mrs. West and her daughter and signed the form to activate the orders. Shortly thereafter, Mrs. West developed fluid retention in her abdomen and her lower extremities. Her physician, not certain if this was due to her known chronic illnesses, recommended sending her to the hospital emergency department (ED) to be evaluated. The daughter did not want her mother to go to the hospital, but Mrs. West consented to her doctor’s recommendation. She was admitted to the hospital after evaluation in the ED. The hospitalist urged her to go on dialysis. Mrs. West adamantly refused but the hospitalist persisted. The daughter called the nursing home social worker who supported their decision and encouraged them to be firm and clear with the hospitalist. The daughter repeatedly assured the hospitalist that they’d thought this through in the POST advance care planning process. Mrs. West summed it up, “I’m 92 years old. I’ve lived a long and good life. I don’t want to spend the rest of my life dependent on being hooked up to a dialysis machine. If this is all you have to offer me, then I don’t need to be at the hospital. I want to go back to the nursing home where I live.” Mrs. West returned to the nursing home two days later and the POST form was reviewed, voided, and a new one completed with the change from “Limited Medical Interventions" to “Comfort Measures.” Mrs. West was moved to a palliative care room and hospice became involved. She died comfortably three weeks later. Mrs. West’s case illustrates how proactively and effectively the POST Advance Care Planning discussion helped her think through, identify, and communicate her values and goals of care to her family and to those providing her medical care. It beautifully highlights that the advance care planning process is dynamic and fluid. As a person’s medical condition changes, it’s necessary to review the POST form and see if the person’s wishes for treatment have changed.
  • Post -a better means for communicating end of life care wishes

    1. 1. Laura Pole, RN, MSN, OCNS Virginia POST Collaborative
    2. 2. “Death is an inevitable aspect of the human condition. Dying badly is not.” Jennings, et al, 2003
    3. 3.  Need for more specific advance care planning at the end of life.  The process of making POST available in Virginia as a communication tool for end of life care wishes.  How POST is affecting end of life care at the bedside.  Resources
    4. 4. An Index Case Mr. Jan
    5. 5.  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
    6. 6. In the case of a person with a terminal or serious progressive illness, is having a living will and durable medical power of attorney enough ?
    7. 7. Healthy Adults: Emergency Planning People with Progressive Illness: guided planning End Stage Illness: Physician Orders for Scope of Treatment
    8. 8.  Name a Healthcare Agent  Prepare for sudden injury or event  Complete basic Advance Directive Source: Carol Wilson, Riverside Health System; Used with permission
    9. 9.  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
    10. 10.  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
    11. 11.  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. 12.  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.
    13. 13.  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.
    14. 14. 2007 2008 2009 2010 2011 2012 2013 History of POST in Virginia IDEA +1 Local Pilot Project State Stakeholders Grant & In-Kind Support + = Virginia POST Collaborative & 13 Regional POST Programs
    15. 15.  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
    16. 16. 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
    17. 17. ◦ Ongoing training, mentoring and support ◦ POST Pilot Project Training Webpage ◦ Training webinars and presentations ◦ One-on-one consultation
    18. 18.  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
    19. 19.  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.  15 training sessions with nearly 450 facilitators trained from multiple disciplines
    20. 20.  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  Presentations scheduled for May and June 2013  CME credits granted  Future: Conduct train the trainer so that regional pilots can host these trainings.
    21. 21.  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.
    22. 22.  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
    23. 23. Skilled Trained Facilitators Laws, Statutes, Regulations Uniform Policies, Procedures, Standards POST Form Can Care Settings Provide Competent, Compassionate Palliative Care? Collaborative Stakeholders and Coalitions Resources Webpage and Communication Plan Physician Support Advocacy Plan
    24. 24. Roanoke Valley Pilot Project QI Study
    25. 25.  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
    26. 26.  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
    27. 27.  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”
    28. 28.  Review: ◦ Where POST is in Virginia ◦ Contacting your Region’s POST Pilot Project Coordinator  No Pilot in Your Area? ◦ Contact Laura Pole ( for guidelines on implementing POST in your community
    29. 29.  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
    30. 30.  National POLST Paradigm:  VHHA: html  NHPCO: Caring Connections:  National Health Care Decisions Day:
    31. 31.  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.
    32. 32. We could make it holy.