ADVANCE CARE PLANNING AND ADVANCE DIRECTIVES GOALS OF

ADVANCE CARE PLANNING AND ADVANCE DIRECTIVES, GOALS OF CARE CONVERSATIONS AND LIFE-SUSTAINING TREATMENT DECISIONS, STATE-AUTHORIZED PORTABLE ORDERS HOW DO THESE PIECES FIT TOGETHER TO ELICIT AND DOCUMENT PATIENT TREATMENT PREFERENCES? Virginia Ashby Sharpe, Ph. D. , Chief of Ethics Policy (Virginia. Sharpe@va. gov) Lucinda Potter, LSW, Ethics Policy Specialist (Lucinda. Potter@va. gov) National Center for Ethics in Health Care July 25, 2017 National Center for Ethics in Health Care 1

Learning Objectives Participants will be able to: - Identify and differentiate VA policies on eliciting and documenting patient treatment preferences - Describe and differentiate advance directives, lifesustaining treatment orders, state-authorized portable orders - Describe and differentiate key progress note titles for documenting patient treatment preferences - Explain the activities that are within scope and out-of-scope for VA social workers in advance care planning and goals of care conversations with Veterans National Center for Ethics in Health Care 2

Polling Questions • True or False? An advance directive is sometimes used as a DNAR/DNR order • True or False? An advance directive is implemented only after the person who completed it has lost decision making capacity National Center for Ethics in Health Care 3

Supporting personalized, proactive, patient-driven care by understanding and honoring patients’ values, goals, preferences, and decisions. National Center for Ethics in Health Care 4

Relevant VHA Polices • VHA Handbook 1004. 02, Advance Care Planning and Management of Advance Directives (ACP & AD Handbook) • VHA Handbook 1004. 03, Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences (LST Handbook) • VHA Handbook 1004. 04, State-Authorized Portable Orders (SAPO) (SAPO Handbook) National Center for Ethics in Health Care 5

VHA Handbook 1004. 02, Advance Care Planning and Management of Advance Directives National Center for Ethics in Health Care 6

ACP & AD Handbook (1004. 02) • Based on Federal law- Patient Self-Determination Act (PSDA) 1990, 42 U. S. C. § 1395 cc(f): All individuals have a right to express, in advance, their health care preferences in case they lose decision-making capacity • Ensures that VA has processes in place for clinicians to elicit patients’ preferences for future health care in case they lose decision-making capacity and to assist patients in documenting their preferences in an AD National Center for Ethics in Health Care 7

Advance Directives (AD) • ADs are used to document: – An individual’s preferences about future health care decisions in the event that the individual becomes unable to make those decisions (Living Will) – The individual’s appointment of a health care agent (Durable Power of Attorney for Health Care) • VA recognizes any valid: – VA AD (VA Form 10 -0137, VA Form 10 -0137 Spanish. English) – State-authorized AD – DOD AD National Center for Ethics in Health Care 8

Advance Directive Discussions • AD discussions are discussions between an individual and a clinician about the individual’s values and preferences regarding future health care for use at a time when that individual is no longer capable of making health care decisions • AD discussions are NOT required before a person completes an AD • Sometimes an individual will choose not to complete an AD after an AD discussion National Center for Ethics in Health Care 9

Advance Directives • ADs are completed by an individual with decisionmaking capacity, not the surrogate, or the health care provider • ADs can be completed at any time when an individual is well or ill • ADs are not orders – they are not DNR/DNAR orders or other life-sustaining treatment orders National Center for Ethics in Health Care 10

Limitations of Living Wills • May have been completed a long time ago, before the individual got sick and, therefore, not applicable to the current medical condition • May be vague • Preferences, not orders – require interpretation by surrogate decision-maker and team National Center for Ethics in Health Care 11

ACP & AD Documentation • Approved note titles (VHA Handbook 1004. 02): – “Advance Directive” – “Advance Directive Discussion” – “Rescinded Advance Directive” – “Advance Directive Notification and Screening” or other locally developed note title National Center for Ethics in Health Care 12

ACP & AD: Role of Social Workers • Initiate AD discussions periodically (at intervals no longer than 3 years) and when there is a significant change in the patient’s health status • Provide educational materials • Encourage patients to discuss their preferences for future health care with their loved ones • Explain the potential benefits of AD discussions and ADs • Highlight the benefits of appointing a health care agent • Describe the limitations of ADs • Document AD discussions and enter ADs into the EHR • Review/rescind ADs the patients wants to review/rescind • Provide assistance to patients who want to complete an AD • Conduct AD notification and screening National Center for Ethics in Health Care 13

VHA Handbook 1004. 03, Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences National Center for Ethics in Health Care 14

Polling Questions • True or False? The VA Life-Sustaining Treatment Decisions Initiative is currently being rolled out across all VHA facilities • True or False? The VA LST Handbook requires a goals of care conversation with all VA patients • True or False? The VA LST Handbook will replace the VA Advance Care Planning and AD Handbook National Center for Ethics in Health Care 15

LST Handbook (1004. 03) • The basis for the Life-Sustaining Treatment Decisions Initiative (LSTDI), a VHA national quality improvement initiative to promote personalized, proactive, patient-driven care for Veterans with serious illness • Published January 11, 2017. Facilities have until July 11, 2018 (18 months from the date of publication) to establish facility policy and implement new practices National Center for Ethics in Health Care 16

LST Handbook (1004. 03) • Standardizes processes related to: – Conducting goals of care conversations (Go. CC) with high-risk patients – Documenting goals of care and LST decisions in CPRS – Honoring LST decisions National Center for Ethics in Health Care 17

LST Handbook (1004. 03) • Replaces VA policies related to DNR orders and other VA LST orders • Does NOT replace VA policies related to ACP/AD • Does NOT replace VA policies related to SAPO National Center for Ethics in Health Care 18

Proactive Goals of Care Conversations (Go. CC) • For patients at risk for a life-threatening clinical event within the next 1 -2 years or patients who express the desire to make decisions about life-sustaining treatments – not all patients • Should be initiated prior to medical crisis and in the outpatient setting whenever possible • Patients appropriate for Go. CC can be identified through clinical judgment (“surprise” question) and objective screening tools (e. g. , CAN* scores in Primary Care) * CAN = Care Assessment Need: indicates risk of hospitalization or death National Center for Ethics in Health Care 19 19

Go. CC: Role of Social Workers (and Others) SW/RN/Psych/Chaplain MD/APRN/PA • Proactively identify high-risk patients • Prepare patients for Go. CCs: – Discuss role of surrogate – Elicit understanding of diagnosis/prognosis – Review any AD, SAPO – Elicit patient’s values, goals, and preferences – Provide basic info. about LSTs and services MD/APRN/PA ONLY • Deliver news about diagnosis/prognosis • Establish an LST plan with patient (or surrogate) • Complete LST progress note • Write LST orders • Document the conversation • Assist with AD, if desired by patient National Center for Ethics in Health Care 20

Go. CC Documentation for Social Workers • VHA Handbook 1004. 03 requires facilities to create a note title for discussions conducted by nurses, social workers, psychologists, chaplains • Recommended title: Goals & Preferences to Inform Life-Sustaining Treatment Plan • Recommended that this note appear in CWAD/Postings so it will be easy for other team members to retrieve National Center for Ethics in Health Care 21

VA LST Orders • DNAR/DNR orders or any other orders to limit or not place limits on one or more LST • Orders written by a practitioner, based on a Go. CC with a patient or the patient’s surrogate • Valid in VA • NOT valid outside of VA National Center for Ethics in Health Care 22

What’s the Difference Between VA LST Orders and Advance Directives? National Center for Ethics in Health Care 23

VHA Handbook 1004. 04, State. Authorized Portable Orders (SAPO) National Center for Ethics in Health Care 24

Polling Questions • True or False? A Veteran’s State-Authorized Portable Orders (SAPO) should align with the Veteran’s VHA LST orders • True or False? A Veteran wouldn’t need both an AD and SAPO National Center for Ethics in Health Care 25

SAPO Handbook (1004. 04) • Ensures that VA has processes in place for practitioners to recognize, honor, offer, and write state-based portable orders regarding life-sustaining treatment National Center for Ethics in Health Care 26

SAPO • Portable orders • Established by states and vary from state to state – POLST, MOST, POST • Honored outside of VA • Honored in VA when presented with a VA patient in a lifethreatening emergency. VA health care providers otherwise act on the basis of VA LST orders • Appropriate for high-risk VA patients residing in the community • Written by VA practitioners who also meet state requirements • Based on a Go. CC with a patient (or the patient’s surrogate) • Must align with VA LST orders to ensure patient decisions honored National Center for Ethics in Health Care 27

SAPO: Role of Social Workers • When preparing patients for Go. CCs: – Review any SAPO to help ensure that SAPO align with VA LST orders • Assist practitioners in offering/providing SAPO to: – Veteran (or the Veteran’s surrogate) who request SAPO – Veterans for whom VHA LST orders have been written in the context of their VHA care and prior to discharge for Veterans who have existing SAPO National Center for Ethics in Health Care 28

SAPO Documentation • Currently SAPO must be linked to “Out-of. Hospital Orders” note title (Next version of SAPO Handbook expected to allow greater flexibility for local note title) • SAPO are documented in EHR for information only; they are translated into active VA LST orders National Center for Ethics in Health Care 29

Webinar Summary • Three VHA policies describe different tools in the toolbox to elicit, document, and honor patients’ values, goals, preferences, and decisions: – ACP & AD Handbook: Living Wills and Durable Power of Attorney for Health Care – LST Handbook: VHA LST Plan and orders – SAPO Handbook: State-based portable LST orders • Lead role for SW in assisting patients with AD • Supporting role for SW in Go. CC to assist practitioners who complete LST progress note, write VA LST orders and SAPO National Center for Ethics in Health Care 30

Comments Questions National Center for Ethics in Health Care 31

NCEHC Policy Website • http: //vaww. ethics. va. gov/activities/policy. as p National Center for Ethics in Health Care 32

Resources • Ethics Center’s website: http: //vaww. ethics. va. gov/ • VHA Training for Staff Who Provide Information and Assistance with Completing Advance Directives • ACP & AD FAQs • LST FAQs • TMS Webinar: Introduction to Eliciting Values, Goals, and Preferences When Patients Have a Serious Illness • TMS Webinar: Team-Based Approaches to Eliciting Values, Goals, and Preferences When Patients Have a Serious Illness • Model Medical Center Memorandum for VHA Handbook 1004. 03 • VHA Progress Note Titles- ACP, LSTDI, SAPO National Center for Ethics in Health Care 33