The document discusses improving end-of-life care through better communication of patients' wishes. It divides the population into three groups based on health status and discusses different trajectories of chronic illnesses near death. It emphasizes that advance care planning conversations are important so treatment decisions are not made in times of crisis or grief, but rather reflect patients' values and goals. The document also discusses Physician Orders for Life-Sustaining Treatment (POLST) forms, which provide medical orders across care settings to communicate end-of-life treatment preferences. It notes POLST is voluntary but provides a consistent recognized document, and is appropriate for patients whose doctors would not be surprised if they died within a year.

1. Increasing Appropriate Hospice and
Palliative Services through
Improved Communication and
Documentation of Patients’ Wishes
Elizabeth Balsam Hart, MD
MaineGeneral Health
With support from the Practice Change Fellows Program,
the Atlantic Philanthropies and the John A Hartford Foundation

2. “How people die remains in the memories of those
who live on.”
Dame Cicely Saunders

3. 3
Divisions by Health Status in the Population and
Trajectories of Eventually Fatal Chronic Illnesses
Joanne Lynn, MD, MA, MS, Center to Improve Care of the Dying, RAND
Divisions in the Population
Group 1
Group 2
Group 3
“Healthy,” needs
acute and
preventive care
“Chronic, not
“serious”
Chronic,
progressive,
eventually fatal
illness
Major Trajectories near Death
AA
Time
Low
High
FunctionFunction
death
Time
BB
Low
High
Function
deathdeath
CC
TimeTime
LowLow
High
Function
death

4. Advance Care Planning
 Often the concerns and wishes we have for end-
of-life care emerge as the situation unfolds, or are
never discussed, rather than making intentional
choices, based on thoughtful discussions in
advance about quality of life, values, risks and
benefits, and goals of care
 We often make the most difficult decisions in a
time of crisis, under a shadow of grief, or at a time
when communication between those involved
may be challenging

5. Conversations - not just forms
• Advance Care Planning is …
• “A process of coming to understand, reflect
on, discuss, and plan for a time when you
cannot make your own medical decisions and
are unlikely to recover from your injury or
illness.”
» Making Choices™
» Planning in Advance for Future Healthcare Choices
» Gundersen Lutheran Medical Foundation

6. Purpose of POLST (Physician Orders
for Life-Sustaining Treatment)
To provide a mechanism to communicate
patient preferences for end-of-life
treatment across treatment settings

7. What is POLST ?
• A Set of Actionable Medical Orders
• Can be completed by any healthcare professional, but
must be signed by a licensed physician*
• Complements, but does not replace, advance
directives
• Voluntary use, but provides consistent recognized
document
*In some states a nurse practitioner or physician assistant may sign the POLST form

8. The Surprise Question
• Would you be surprised if your patient
with advanced cancer died in the next
year?”
• If the answer is “No”, likely appropriate
for POLST
• Connections between POLST model and
Cancer Plan Objectives 15.1 – 15.7