1. Serious Mental Illness and Advanced
Medical Illness: We’re SupPOLST to
do WHAT?
Diane Danly, MD
Primary care
Palliative Care
Hospice Medical Director Board Certified
6/7/2016 1
2. Objectives:
Identify and
describe the risk of
advanced medical
illness in those
with serious
mental illness
(SMI).
Discuss ethical
aspects and
practical
challenges of
caring for patients
with SMI and
advanced medical
illness (AMI).
Explore barriers to
effective disease
modifying and
palliative
interventions in
those with SMI.
Define shared
clinical decision
making.
Describe effective
use of the POLST as
a tool to
communicate goals
throughout care
transitions in
patients with
serious illness.
6/7/2016 2
3. Disclaimers and Definitions
Disclaimer:
• This presentation is being offered by Eastern State Hospital for educational
purposes, and is not to be considered medical advice or treatment.
• Dr. Danly has nothing to disclose.
Definitions:
HRQOL=Health related quality of life
AMI= Advanced Medical Illness
SMI= Serious Mental Illness
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4. Experience of the audience:
• How many care for patients who have more than
one advanced medical comorbidity?
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• How many care for patients who may die in the
next year or two?
6. Mortality rate in those with SMI:
• Women die 10-18 years younger than general
population (81 is average in US)
– Average age 67
• Men die 8-19 years younger than general population
(76 is average without mental illness in US)
– Average age 63.
• Majority of excess death is attributed to:
– cardiovascular disease (>>heart disease)
– respiratory illness
– Cancer
– less so by suicide or accidental death.
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Ref. 5, 9
7. Mortality Gap is Increasing
“Despite advancements in
medical care, patients
with schizophrenia are not
benefitting from advances
in healthcare to the same
extent as the general
population.”
Hodgson R et al, 2010
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8. More risk of AMI
Medical Condition, Prevalence and Relative Risk Compared to General Population
Modified Risk Factor Schizophrenia RR Bipolar RR
Prevalence % Prevalence%
Obesity 45-55 1.5-2 21-49 1-2
Smoking 50-80 2-3 54-68 2-3
Diabetes 10-15 2-3 8-17 1.5-3
Hypertension 19-58 2-3 35-61 2-3
Hyperlipidemia 25-69 Less than 0.5 23-38 Less than 0.3
Metabolic
syndrome
37-60 2-3 30-49 2-3
(9)World Psychiatry. 2011 Feb; 10(1): 52–77.
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9. SMI status
• Associated with 2-3 fold greater odds of having more health
problems, esp. chronic
• 26% of those w/ mental illness also meet criteria for
substance abuse disorder
• Mortality rate for schizophrenia is 2X > rest of population
• Controlling for behavioral factors, such as smoking, drug use
and inactivity, does not eliminate the impact on heart disease
related mortality
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Ref. 5, 6, 7
10. Barriers to treating medical conditions in those w/ SMI
1. Lifestyle factors:
– substance use, diet, lack of
exercise and obesity
2. Side effects of medication
3. Effects of illness:
– cognitive impairment, social
isolation and lack of family
support
4. Pain response:
– Higher pain threshold,
reduced sensitivity to pain
or reduced reporting of pain
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11. Barriers to medical treatment in SMI, continued
• Suspiciousness, fear
• Self-neglect
• Lack of motivation
• Socio-economic factors
• Impaired effectiveness
in communicating
health care needs
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12. System-Wide issues:
Poverty & Lack of
Resources
•Mental Health is often under-funded
Unequal quality of
medical care:
•patients are less likely to:
•Receive CABG with 3 vessel CAD
•Have arteriography after stroke
•Have diabetes optimally managed
Separation of
Psychiatry &
Medical:
•lack of care integration and coordination.
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13. Provider Barriers:
• Stigma of SMI
• Time and resource constraints
• Physical complaints may be
seen as psychosomatic
symptoms
• Risk of drug misuse in those
with drug issues
• Fears about talking about end of
life and causing escalation of
psychotic symptoms
• Not having adequate training in
how to have these
conversations
6/7/2016 13Ref. 5, 7
14. Stigma X 7 in advanced disease
• SMI
• Dying
• Elderly
• Memory impairment
• Poor
• Often disenfranchised by
family/society
• At risk for “demoralization
syndrome”
– Shame and guilt from past
Madrigal, 2006
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15. Can patients with SMI make medical decisions?
“Persons with mental illness (PWMI) are often not afforded the same
opportunity to make decisions on a par with others in society. Article 12 of
the International Convention on the Rights of Persons with Disabilities (CRPD)
states that persons with disabilities should have equal recognition before
the law and the right to exercise their legal capacity.”
“Exercising legal capacity can mean making decisions about employment,
medical or psychosocial treatment, property, finances, family, and
participation in community activities… There is also a general paucity of
research evidence for supported decision making, with the majority of
research focusing on shared decision-making for treatment decisions. “
Public Health Reviews, Vol. 34, No 2 “Supported Decision-Making for Persons with Mental Illness:
A Review” Soumitra Pathare, MD, 2013
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17. What is informed consent?
3 essential components of
informed consent are:
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1) No
coercion
2) Patient is:
given all
information
to decide
3) Patient is:
an adequate
decision
maker
18. “Decision making capacity” vs. “Competence”
• comprehend the information about the nature of their
condition, the procedures involved, as well as the risks
and benefits
1. Understand
• appreciate the significance of the disclosed information
and the potential risks and benefits for one’s own
situation and condition;
2. Appreciate
• engage in a logical reasoning process about the risks and
benefits versus alternatives, and3. Reason
• a consistent choice4. Express
*Assessment of patients’ competence to consent to treatment. NEJM 2016
6/7/2016 18
…Does the Patient:
19. Be clear…
• Competence is a legal determination made by a court of law
• While the court may consider information about a patient’s
decision-making capacity in making a competency
determination, the terms are not synonymous.
6/7/2016 19
“Decision-Making
Capacity”
“Competence”
20. Ethical aspects: four principles
• self- rule or human dignityAutonomy
• bring good about with all
of our actions
Beneficence
• treat all people as though
they are equal and worthy
of care and respect
Justice
• to do no harm, or minimize
impact of harm when
possible
Non-
maleficence
6/7/2016 20
21. Models of Medical Decision Making in AMI
• Patient given as
much autonomy as
able, w/ support of
identified durable
power of attorney,
using patient
values
• “I want
this.”
• E.g: “Choosing
Wisely” campaign
by Society of
Internal Medicine
• “you are
going to have
to do this.”
Clinician
led
Shared(=)
Supported
decision
making
Patient led
6/7/2016 21
*Different approaches may be appropriate at different times (Coulter)
22. Models of Medical Decision Making in AMI
Shared medical decision making regarding:
– tests
– procedures
– treatments
= more accurate informed consent
Shared AND supported decision making =
• improved patient satisfaction
• treatment adherence and
• improved health outcomes
– (such as symptoms better managed)
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23. Palliative Care:
Model of shared/supported decision making
a. Palliative care (pronounced pal-lee-uh-tiv):
– specialized medical care for people with serious illness
– focused on providing relief from the symptoms and stress of
serious illness
– goal is to improve quality of life for both the patient and the
family
b. Specialty palliative care:
– provided by a trained team of doctors, nurses, social workers
and other specialists
– All work together to provide an extra layer of support.
– Appropriate at any age and at any stage in a serious illness and
can be provided along with curative treatment.
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25. Overlap of hospital psychiatric & palliative models of care:
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Team-based
Collaborative
Focus on patient
goals
Whole person care:
spiritual,
psychological,
social
Family and
community
centered
Focus on
experience/quality
of life
27. Have the Conversation.
Pre-meeting set up:
Tell me what you understand…
What concerns you the most?
What are your hopes?
What does “quality of life” look like to you?
What is unacceptable to you?
What are your biggest fears?
When your time does come to die, where would you like to be?
Summarize: Do I have it right?
6/7/2016 27
“Based on what
you have said:
let us fill out your
POLST so your
preferences will
be honored”
28. What is important in SMI-HRQOL
.Barriers from illness
placed on
relationships
Reduced control of
behaviors and actions
Loss of opportunity to
fulfill occupational
roles or achieve
certain aspirations
Financial constraints
on activities and goals
Subjective experience
of psychotic
symptoms
Side effects and
attitudes to
medication
Psychological
responses to living
with the condition of
schizophrenia
Labelling and
attitudes from others
Worries about the
future and
Positive outcomes
from experiences.
Quality of life in
schizophrenia; Gee,
2003
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30. The Palliative care approach can be applied by medical
and psychiatric care providers
You tube video, Palliative care
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31. Palliative care principles
Set realistic
goals
(FOCUS=GOALS)
Reduction of
side effects
Symptom
management
Targeting
identified
psychological
and social
problems
•Sound familiar?
Reducing
burdensome,
potentially
harmful
medical
interventions as
illness
progresses
GOAL:
improved
HRQOL for
patients
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32. Communicating choices…
Many people have clear ideas of their choices but
don’t share this information with family and
physicians.
-WSMA.org
*Advance Directives – basically a “living will” and
durable power of attorney for health care
-> Indication: age 18 years+, and be alive
*POLST form (Physician Orders for Life-Sustaining
Treatment)
-> Summarizes a patient’s wishes into actual
physician orders.
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33. Who will benefit from a POLST?
• Have a chronic, progressive illness that
cannot be cured
• Have a serious health condition, or
• Are medically frail
• Those with chronic illness who prefer to
avoid life prolonging treatment or desire a
no CODE status, preferring to die a natural
death.
https://csupalliativecare.org/programs/polst/
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35. Why not use Advanced Directives?
Doesn’t
translate into
physician order
Usually
not
available
Not
specific
enough
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*The POLST has been
shown to:
• Improve communication of
goals of care & interventions
• Help when patients shift
between sites of care as their
functional condition advances
or recedes
• Be highly successful in Oregon
and Washington
36. True or false?
True or false: Palliative care approach is associated
with shorter lifespan.
6/7/2016 36
37. True or false?
True or false: Palliative care approach is associated
with shorter lifespan.
– FALSE. Improved lifespan and HRQOL and less
curative directed treatment (less ineffective
treatment). JAMA 2010
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39. CPR outcomes
What is the 6 month survival rate of those with
multiple advanced comorbidities (cancer, diabetes,
renal failure, etc.) of discharge from the hospital?
a. 12.5 %
b. 25%
c. 75%
d. less than 2%
6/7/2016 39
40. CPR outcomes
What is the 6 month survival rate of those with multiple
advanced comorbidities (cancer, diabetes, renal failure, etc.)
of discharge from the hospital?
a. 12.5 %
b. 25%
c. 75%
d. less than 2%
Although 7.2% of CPR recipients without chronic disease were
discharged home and survived at least 6 months without
readmission, ≤ 2.0% of recipients with advanced COPD, CHF,
malignancy, and cirrhosis (P < .001 for all) met these criteria.
6/7/2016 40
44. Effective decision making is dependent on…
Accurate information
Values of the patient honored (not the care provider)
Preferences of the patient
Outcomes that are patient driven
Models are being developed on guiding decision
making SMI and AMI, research actively undergoing.
6/7/2016 44
47. Shifting locations of all patients with AMI
AMI
• Acute medical hospitals
• Acute rehab hospitals
• Extended care homes
• Nursing homes
• Rehabilitation Centers
• Homes (with or without family/hired
caregivers/hospice care for them)
• Group Homes/Assisted living
• Hospice houses
• Adult Family Homes
SMI and AMI
• Acute medical hospitals
• Jails
• Homeless/streets/shelters
• State Mental Hospitals
• Homes
• Group Homes/Assisted living
• Memory care facilities
• Hospice houses
• Nursing homes (if on stable meds
and no violence)
6/7/2016 47
POLST serves to communicate choices
across care environments; EMR helps
48. Cerner POLST instructions
6/7/2016 48
1. Once in Cerner, select ‘patient list’ from the
organizer bar and click open a patient’s chart.
2. From left side of Menu click Orders tab which
will open patient order list.
3. Click blue plus sign from upper left corner of
main viewing area which will open an add order
box.
4. In search field type POLST.
5. A drop down menu of POLST order options will
appear to select from.
50. Actual POLST plan of care selected from above drop down.
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51. Organ donation
ESH participates
in the LifeNet
Organ donation
program
Documentation of
their involvement
is found in the
treatment teams
comfort care/end
of life order set
Policy 1.79 on the
Admin Policies
Sharepoint site
Many feel it is an
honor to be an
organ donor
6/7/2016 51
52. Summary
Patients with SMI have:
• less access to adequate medical care, including specialty
palliative care
• poor compliance/suboptimal management w/medical
treatments
• special barriers to community resources, sometimes higher
needs that can be safely accommodated outside hospital setting
• preference for autonomy, with values and dignity respected
• desire to participate in decisions:
• “shared decision making” currently thought to be best model
• Further research pending
6/7/2016 52
