1. Physician Orders For Scope Of Treatment: The Roanoke Pilot Project for POST Karen Mayhew, LCSW Director of Patient Services, Good Samaritan Hospice Missy Ring, RN, CHPN Clinical Team Leader, Carilion Clinic Hospice

2. Advance Care Planning: A Work in Progress In hospice care, we have long known, as said by Bill Moyers in On Our Own Terms, the importance of recognizing two things: the individuality of each disease and the individuality of the person with that disease.

3. Could This Happen In Roanoke? Mr. Dehart, a 71 year old hospice patient with severe COPD and mild dementia, resides at home with his wife. He develops increasing SOB and his wife calls 911. When EMS arrives, the adult daughter, visiting from out of town, advises them the family wants everything done. The wife does not mention her husband’s DDNR. EMS staff, having found the patient unresponsive, try to intubate him, but cannot. They insert an oral airway and transport the patient to the ER. Mr. Dehart remains unresponsive with a RR of 8 and an O 2 sat of 85% despite supplemental O 2. Pursuant to a chest X-ray, the ER physician writes, “full code for now, status unclear.” The staff intubate Mr. Dehart and transfer him to the intensive care unit.

4. What Went Wrong?

5. DDNR order not communicated to EMS and in subsequent transfer. Advance directive not documented. (Do you think advance directive would have been followed in this situation if it were documented?) Family at odds with patient’s wishes. Lack of communication between healthcare providers – hospice left out of loop. Results include overtreatment of patient with unnecessary physical discomfort, costs, and prolonged dying process.

6. “ The problem with communication is the illusion that it has been accomplished.” - George Bernard Shaw

7. Common Issues With Advance Directives Advance Directives (AD) frequently use statutory language that can be hard to understand. Healthcare staff trying to assist patients in completing an AD often focus on how to complete the form, not adequately discussing the issues at hand. Focus has been more on legal rights and less on help for patient in making informed decision about his/her individual care.

8. Advance Care Planning: Addressing The Communication Gap 12 States have already implemented pilot programs for POST, or a similarly named document (e.g., POLST/MOST), in order to close gap between patient wishes and actual treatment: Physician’s order greatly increases likelihood of adherence to patient wishes. POST document must accompany patient from one healthcare provider to the other. POST better informs healthcare staff of patient wishes in that it identifies clear, specific choices... less room for interpretation.

9. What is POST? Physician-signed order for communicating and implementing patient preferences for end-of-life treatment. Short summary of actual treatment preferences, including CPR, need for hospitalization & related procedures, antibiotics, artificial nutrition and hydration. Approved as a legal durable DNR by the Virginia EMS office. Is in keeping with Virginia Health Care Decisions Act. Can stand alone as a healthcare document or in conjunction with advance directive Encourages centralizing of patient’s pertinent healthcare information, e.g., living will, Medical POA, organ and tissue donation, etc. Provides for standard method of transfer across treatment settings.

10. Who Is Eligible For POST? 1. Seriously ill persons, i.e., those with chronic, progressive disease 2. Terminally ill persons

11. Who Is Eligible For POST? Prompt for POST completion: Would I be surprised if this patient died in the next year?

12. Living Will vs. POST (Remember: Patients may have both forms.) Living Will* For every adult regardless of health Decisions about open-ended myriad of treatments Needs to be retrieved Normally requires interpretation (*Hastings Center Report 2004; 34: 30 – 42) POST For seriously or terminally ill adults Decisions among presented treatment options Stays with patient Physician’s order for specific treatment(s)

13. Roanoke Pilot Program for POST

14. Roanoke Pilot Program for POST Has been developed under auspices of the Palliative Care Partnership of the Roanoke Valley (www.pcprv.org).www.pcprv.org Training in advance care planning and facilitation of the POST form is being provided by Respecting Choices (RC), a nationally recognized program of the Gundersen Lutheran Medical Foundation. In the Roanoke area, currently 35 healthcare professionals have been trained as Advance Care Planning Facilitators through RC. The POST pilot project in Roanoke is scheduled to begin 9/1/09 and will continue over the next 2 years, with the goal of making POST a legal document recognized throughout Virginia.

15. Roanoke Pilot Program for POST Important Note: Only patients who reside in the following locations are eligible to participate in the POST pilot program: Roanoke County Friendship Health & Rehab Center Richfield Recovery & Care Center

16. Who Is Participating In The Pilot? Palliative Care Partnership of the Roanoke Valley Friendship Health and Rehabilitation Ctr. Richfield Recovery and Care Ctr. Carilion Clinic: Roanoke Memorial Hospital Lewis-Gale Hospital (pending approval) 4 Area Hospices Amedysis Hospice Carilion Clinic Hospice Good Samaritan Hospice Medi Home Hospice Medical College of VA (MCV) in Richmond is also linking to RKE pilot program

17. Other Participants: EMS & Local Medical Transport Companies Roanoke City Fire & Rescue Roanoke County Fire & EMS Salem Fire & EMS Carilion Clinic Patient Transport Guardian Life Care United Ambulance Service

18. POST Form

19. The Conversation POST discussions must be facilitated by the patient’s physician or a trained Advance Care Planning Facilitator (ACPF). The facilitator may choose to involve other members of the patient’s healthcare team as well. The dialogue may or may not result in the completion of a POST document, but it does create an environment of shared and informed decision making for the patient facing serious illness.

20. Role of ACP Facilitator 1. Explores patient’s understanding of advance care planning and the role of a healthcare representative. 2. Explores understanding of medical condition, including possible complications that may occur. 3. Provides meaningful context for decision making through identifying previous key healthcare experiences, fears & worries, values, and important beliefs. 4. Explores patient’s understanding of CPR, comfort care, antibiotics, artificial nutrition and hydration, etc. 5. Ensures that patient’s wishes are clearly documented on transferable form. 6. Develops list of pertinent questions that may involve physician and others.

21. The POST Form 21

22. 22

23. Section B: Medical Interventions If in the “terminal” phase, POST and advance directive should be consistent Care plan should always be consistent with POST If Comfort Measures are selected consider hospice consultation 23

24. Section A: Resuscitation DNR orders only apply if a person has no pulse and is not breathing Note: This section has 2 choices: Attempt Resuscitation and Do Not Attempt Resuscitation: Check to see which box is checked! POST Section A recognized as a valid Virginia Other DNR. When Do Not Attempt Resuscitation is checked, qualified healthcare personnel are authorized to honor this order as if it were a Durable DNR order OEMS approval (Michael Berg) 24

25. Levels of Medical Interventions Comfort Measures Treat with dignity and respect. Keep warm and dry. Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Transfer to hospital only if comfort needs cannot be met in current location. Also see “Other Instructions” if indicated below. 25

26. Levels of Medical Interventions Limited Additional Interventions Include comfort measures. Do not use intubation or mechanical ventilation. May consider less invasive airway support (e.g., CPAP or BiPAP). Use additional medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. Hospital transfer if indicated. Avoid intensive care unit. Also see “Other Instructions” if indicated below. Full Interventions In addition to Comfort Measures above use intubation, mechanical ventilation, cardioversion as indicated. Transfer to hospital if indicated. Include intensive care unit. Also see “Other Instructions” if indicated below. 26

27. Section C: Artificial Nutrition These orders pertain to a person who cannot take food by mouth Feeding tube for a defined trial period: Gives option to determine benefit to patient and/or recovery from stroke, etc. 27

28. POST Sections (Other)  Discussed with  Physician (or PA or NP) Signature and contact info  Patient/Authorized Decision Maker  Authority to sign patient if patient is incapacitated  Facility of POST form origin  Name and signature of Facilitator  Instructions 28

29. 29 Questions???

30. No problem... My colleague, Missy, will be glad to answer that!

31. Location And Transfer Of POST Form

32. Location Of The POST Form The original POST form (canary yellow color) must always accompany the patient when transferred or discharged. The POST form is transferred in a large red envelope, which stays with the original document (see next slide). In Nursing Facility: Will be kept in the very front of patient’s chart. In Patient’s Private Residence: should be kept on refrigerator door, either in red envelope or with easy access to red envelope.

33. The Red Envelope for Transfer/Discharge

34. Envelope Label ORIGINAL POST/DDNR Form Enclosed Form is to accompany Resident upon Discharge/Transfer PLEASE RETURN ORIGINAL FORM IN THIS ENVELOPE TO: (Patient Name) (Address)

35. Transfer Of POST With Patient Red envelope with original POST should be placed on top of transport papers. The healthcare facility initiating the transfer shall communicate the existence of the POST form to the receiving facility prior to the transfer. The POST form shall accompany the person to the receiving facility and shall remain in effect.

36. Modifying POST Decisions

37. Revoking/Making Changes to POST If the resident wishes to change the POST form, the original POST form shall be voided, and a new one completed.

38. Revoking/Changing a POST Form To change POST, the current POST form must be voided and a new POST form completed. If no new form is completed, full treatment and resuscitation may be provided. As long as the patient can make his/her own decisions, then the patient can revoke consent for POST and also may request changes to POST.

39. Revoking/Making Changes to POST If a patient tells a healthcare professional that he wishes to revoke his consent to POST or change POST, the healthcare professional caring for the patient should draw a line through the front of the form and write “VOID” in large letters on the original, with the date and their signature, and notify the patient’s physician. A new POST form then may be completed if desired by the patient. The physician or a POST ACPF may complete the new form.

40. Revoking/Changing POST If “Do Not Attempt Resuscitation” is checked in Section A and the patient has signed this form, no one has the authority to revoke consent for the DDNR order other than the patient as stated in the Code of Virginia section 54.1- 2987.1.

41. Revoking/Changing POST If the patient signs this form, then the patient’s overall treatment goals should be honored if the patient later becomes unable to make decisions. If the patient is unable to make healthcare decisions, a legally authorized medical decision maker, in consultation with the treating physician, may sign this form, revoke consent to, or request changes to the POST orders (except in section A as noted above) to continue carrying out the patient’s own preferences in light of changes in the patient’s condition.

42. Revoking/Changing POST The voided POST form shall be placed in the Advance Directives section of the thinned chart.

43. When Not To Complete A POST Form A POST form should not be completed if the patient requests contradictory orders. One of the most likely examples: the patient wants CPR in Section A, but wants only limited additional interventions in Section B. The performance of CPR requires full treatment. If the patient does not want full treatment, including intubation and mechanical ventilation in an ICU, then the patient should not receive CPR.

44. Questions???

45. If you can do the Medicare CoP’s, you can do anything! Hospice Readiness

46. Develop a policy and procedure for POST (a sample is available from the PCPRV or Karen or Missy. Establish way for staff to alert each other to patient’s POST form and to be aware of patient preferences. Develop method for reviewing POST form upon admission and as patient’s condition or preferences change. Will need to designate method for photocopying and storing in record. Develop procedure for ensuring that POST form is transferred with patient from one healthcare setting to another.

47. Hospice Readiness Ensure training for staff who missed this inservice and provide orientation to POST for new staff. See that adequate number of hospice staff become trained Advance Care Planning Facilitators (Respecting Choices training to be offered again in Roanoke in 12/09) so that your hospice can initiate POST on behalf of eligible patients. Acquire forms and envelopes through PCPRV, as needed, for use by trained facilitators. Designate staff representative to become involved in pilot program through PCPRV and to offer/receive feedback as this program evolves. Periodically remind staff of POST and your procedures.

48. POST Resources Palliative Care Partnership of the Roanoke Valley www.pcprv.org Contact Person for POST: Laura Pole, lpchef@earthlink.net Respecting Choices www.respectingchoices.org See list of attached area professionals who are certified as Trainers and/or Facilitators in Advance Care Planning

49. Remember: Pilot Program Begins On 9/01/09 Thank You For Your Time & Help In Bringing POST To Hospice Patients! Missy & Karen & The Palliative Care Partnership of the Roanoke Valley