Just how does the Advance Directive Relate to

Just how does the Advance Directive Relate to the POST? BERNARD “BUD” HAMMES, PHD GUNDERSEN HEALTH SYSTEM LA CROSSE, WI WWW. RESPECTINGCHOICES. ORG

POST: An Effective Component of a Comprehensive ACP Program

National POLST Paradigm Programs *As of May 2013 Mature Programs Endorsed Programs Developing Programs POLST-Like Programs No Program (Contacts)

Advance Care Planning… 4 • IS NOT A “ONE SIZE FITS ALL” DISCUSSION • MUST BE INDIVIDUALIZED TO PATIENT READINESS AND STAGE OF HEALTH • REQUIRES ACP FACILITATION SKILLS TO ADDRESS STAGE OF PLANNING

Stages of Advance Care Planning Over the Life Time of Adults First Steps Next Steps Last Steps ACP: Create POAHC and consider when a serious neurological injury would change goals of treatment. ACP: Determine what goals of treatment should be followed if complications result in “bad” outcomes. ACP: Establish a specific plan of care expressed in medical orders using the POST form. Healthy adults between ages 55 and 65. Adults with progressive, life-limiting illness, suffering frequent complications Adults whom it would not be a surprise if they died in the next 12 months.

A Patient’s Story Ø 71 -year-old man with severe chronic obstructive pulmonary disease and mild dementia is admitted to a nursing home after a hospital stay for pneumonia Ø He develops increasing shortness of breath and decreasing responsiveness over 24 hours Ø The nursing staff calls the emergency medical service, who find the patient unresponsive, with a respiratory rate of 12 breaths per min. and oxygen saturation at 85% on room air

Ø The patient had discussed his desire to forgo aggressive, life-sustaining measures with his family and nursing personnel, and completed a POAHC Ø Although a do-not-resuscitate order was written, the emergency team was not informed, and there were no orders for respiratory failure

Ø The emergency team inserts a nasal pharyngeal airway, administers supplemental oxygen, and transports the patient to the ED of a local hospital Ø The patient remains unresponsive and his chest X -ray shows large lung volumes with consolidation. Arterial blood gases show marked respiratory acidosis

Ø The emergency department physician writes, “Full code for now, status unclear. ” The patient is intubated, sedated, and transferred to the intensive care unit Adapted from Lynn, et al. Ann Intern Med 2003; 138: 812 -818

What Went Wrong?

What Went Wrong? � DNR order not communicated within healthcare facility � Lack of clarification of meaning of “no aggressive” treatment with patient � Lack of eliciting patient wishes for all relevant treatment decisions (e. g. , airway management, hospitalization, comfort care) � Patient received unwanted care � System-wide failure to respect wishes Failure to plan ahead for relevant treatment decisions No system for transfer of plan of care between healthcare facilities

POAHC versus POST �POAHC Completed in advance by adult with decision- making capacity Implemented when capacity is lost Provide some general goals and care plan Designates surrogate(s) for future decision-making � POST Completed at any point in time by decisional person or designated surrogate Can guide decisions immediately as medical orders when needed Stays with patient Provides orders for common medical decisions for sickest patients Can be updated by any physician in transitions of care or as needed

POST Paradigm Program for Honoring Preferences OVERVIEW OF KEY COMPONENTS

Goals of the POST Program �To provide timely opportunities for informed, specific end-of-life treatment decisions �For patients with serious, life-limiting illnesses those that are terminally ill advanced frailty others interested in defining their care

Would I be surprised if this patient died in the next year? Pattison, M. , & Romer, A. L. (2001). Improving care through the end of life: Launching a primary care clinic-based program. Journal of Palliative Medicine, 4(2), 249 -254.

Key Features of the POST Program �Serves as a set of medical orders �Is a portable document that transfers from one setting to another with the patient or resident �Provides directions for providing or forgoing aggressive treatment �May function as a Do-Not-Resuscitate (DNR) order, but also provides goals of care for severe cardiopulmonary deteriortation.

POLST Use in Long-Term Care: A Multi-State Study Hickman, SE. , Nelson, CA. , Perrin, NA. , Moss, AH. , Hammes, BJ. , Tolle, SW. A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life-Sustaining Treatment Program. JAGS. 2010. 58: 1241 -1248 Funded by: NIH/National Institute of Nursing Research, R 01 NR 009784 ©Copyright 2008—All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc.

Purpose of Study �To evaluate the effectiveness of the POST Program in comparison to traditional practices. ©Copyright 2008—All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc.

Aim 1 Findings POST and Medical Orders �Residents with POST forms had significantly more medical orders about life-sustaining treatments. N = 1792 Any Type of Order* POST 100% No POST 86% * p <. 001 ©Copyright 2008—All Rights Reserved. Gundersen Lutheran Medical Foundation,

Aim 1 Findings Presence of orders for specific life-sustaining treatments N = 1792 Resuscitation * Medical Interventions * Antibiotics* Feeding Tubes* POST 100% 97. 6% 92. 8% *No p <POST. 001 85. 5% 8. 2% 2. 9% 6. 7% ©Copyright 2008—All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc.

Aim 3 Findings Use of Life-Sustaining Treatments N = 1792 All* No POST 26% POST 16% P <. 001, Odds ratio =. 531 Residents with POSTs were 50% less likely to receive lifesustaining treatments than residents without POSTs ©Copyright 2008—All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc.

The La Crosse Advance Directive Studies (LADS I & II) The Prevalence, Availability, and Consistency of Advance Directives over a 10 -year period after implementation of the Respecting Choices ACP Program 22

Prevalence, Availability, and Consistency of Advance Directives in La Crosse County Decedents with ADs No (%) ADs found in the medical record where the person died LADS I * Data collected in ‘ 95/’ 96 N=540 LADS II** Data collected in ‘ 07/’ 08 N=400 P value 459 (85. 0) 360 (90. 0) . 023 437 (95. 2) 358 (99. 4) <. 001 99. 5% 0. 13 Treatment decisions found consistent 98% with instructions *Hammes BJ, Rooney BL. Death and end-of-life planning in one midwestern community. Arch Intern Med. 1998; 158: 383 -390. **Hammes BJ, Rooney BL, Gundrum J. A comparative, retrospective, observational study of the prevalence, availability, and utility of advance care planning in a county that implemented an advance care planning microsystem. JAGS. 2010. 58: 1249 -1255

LADS II Additional Data � 67% of decedents had a POLST document � 98. 5% of POLST forms were in the medical record of the health organization where the person died �The most recent POLST form was completed 4. 5 months prior to death � 96% of all decedents (n=400) had either an AD or a POLST form at the time of death

Comparison of POLST vs AD Only POLST (N= 268) � Older: Mean age 83 � More likely to die of existing chronic or terminal illness (97% ) � More likely to die in LTC or at home (84%) � 30% of POLST forms were completed by health care agents alone AD only (N= 116) �Younger: Mean age 77 �More deaths from sudden or traumatic causes (18%) �More likely to die in the hospital (59%) or inpatient hospice (23%)

Some POST Nuts and Bolts

Training …two types �How to complete the form, how to manage it within an organization, how to transfer it. �How to work with patients and families or a patient’s surrogates to make informed decisions that are reflected on the POST form. �In most programs non-physicians play a central role in facilitating discussions and decisions with patients, their families, and the patient’s surrogate.

How does POST look in different care settings? �Long-term care Is POST being reviewed at admission and update over time? Is there a clear, standardized place to maintain POST so all can see it? Does POST go with the resident when he or she leave the facility, especially to the ED? Are the people assisting with POST decision trained to assist? How is POST reviewed when the new resident arrives? How is POST employed when there is an acute problem?

Admission to the Hospital �If a patient has a POST form at admission does the admitting physician know this? �Are the existing POST orders appropriately used to write medical orders for this admission? �Is the POST form kept track of and either updated or returned with the person at discharge?

POST and Hospital Orders Gundersen Hosp Order P-DNR = O-DNI/DNR= O-DNR = FULL = POST Section A + B DNR + comfort measures only DNR + limited interventions DNR + aggressive treatment CPR + full treatment

Home Hospice �Is a POST form completed to the degree possible at admission? �Is the POST form complete soon after admission? �Is the family care-givers instructed about where to keep the POST form and how to use it…including who to call if there is an emergency?

Emergency Services �Are 1 st responders and EMT/Paramedics trained to use POST? Is this training updated on a regular basis? �Do they ask for or look for a POST form when called to a scene with a patient who might have a POST, e. g. , LTC, Hospice, Assist-Living. �Do they take the POST with them if they transport the patient? �Do they make sure the ED is aware of the POST form when they hand the patient off?

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