1. Catalyzing Patient Quality of Life Preferences into Medical Care Choices Helen D. Blank, PhD April 2010

2. Situation Assessment – Industry Observations Significant body of research documenting the low quality and high cost of care during advanced illness Quality Studies Cost Studies –Dartmouth Atlas of Health Care –Medical Care Inconsistent With Patients’ Treatment Goals: Association with 1-year Medicare Resource Use and Survival (Teno, Journal American Geriatric Society, 2002) –Health Care Costs in the Last Week of Life Association with End-of-Life Conversations (Zhang, Archives of Internal Medicine, 2009) –Patient and Family Centered Outcomes at the End of Life (Teno, JAMA, 2004) –Opportunities to Improve the Quality of Care for Advanced Illness (Krakauer, Health Affairs, 2009) –Patient and Family Centered Outcomes at the End of Life (Teno, JAMA, 2004) –Trends in the Aggressiveness of Cancer Care Near the End of Life (Earle, JCO, 2004) –Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death & Caregiver Bereavement (Wright, JAMA, 2008) –Beyond Information Exploring Patients’ Preferences (Epstein, JAMA, 2009) –Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer (Huskamp, Archives of Internal Medicine, 2009) –Family Perspectives on End-of-Life Care at the Last Place of Care (Teno, JAMA, 2004) Note: For discussion purposes advanced illness is defined as a member health situation which will likely result in death over the course of the next twelve months.

3. Physicians don’t uniformly have the training, time, and financial incentive to effectively implement shared decision making during advanced illness –Structural changes to delivery system over the long term are required to address these deficiencies Payers have historically addressed the issue through medical utilization and case management strategies often creating a battle of economic interests –Covered benefit determination then peer review for necessity –Care coordination & monitoring to optimize implementation efficiency of largely inefficient care decisions –Ignores the fact that patients have intrinsic but often unexpressed quality of life preferences that favor less aggressive curative treatment options than the status quo. Patients don’t currently recognize the need, have the knowledge, or possess the confidence to participate in, let alone drive, care decision making processes in order to effectuate their quality of life preferences Situation Assessment – Industry Observations “The data – and my clinical experience – suggest that when patients and doctors spend the time to talk about their values and goals and the likely outcomes of proposed treatments most – but not all – will opt against a trial of all life-prolonging technologies available.” Dr. Sean Morrison, Director NPCRC Vital Decisions SAB Member

4. Our Solution & Value Proposition To catalyze the intrinsic but often unexpressed patient quality of life preferences into care decision making in order to increase the efficiency and quality of care Medical Ethics Goal Setting QoL Issues Cultural or Personal Values Advanced Illness Counseling Understanding & Acceptance Behavioral Change Communication Advocacy Skills Conventional Advance Care Planning Weighing Treatment Options Pain Issues Documentation e.g. ADs Hospice & Palliative Care Expert Staff Experience Base Proprietary Methodologies Neutrality Providing Skilled Navigation Through Areas That Others are Reluctant to Explore

5. Vital Decisions Living Well Program Goal & Strategy To create patients and families who proactively participate in their care by identifying, communicating and incorporating their quality of life priorities into current and future care decisions Create an Informed Patient Identify Quality of Life Priorities Integrate Priorities into Care Decisions Develop Plan, Communicate & Revise Current Medical Situation Future Medical Situation Scenarios Current and Future Quality of Life & Care Decisions/Alternatives Transition Points Independence, Interactivity, Comfort Current & Future Care Decisions that Support Priority Achievement Current & Future Ensure Effectuation of Priorities Throughout Illness Progression Integrate with Family & Providers Communication Vehicles & Support Create an Active Patient Stage Based Behavioral Change Strategies and Activities Embedded in Process Proprietary Methodology Developed in Conjunction with Prochaska for Advanced Illness Population Active on Current & Future Scenarios

6. Vital Decisions Living Well Program Process Overview Scripts and Branching Logic (Conversation Flow) Tools & Decision Aids for Patient & Counselor Counseling Workflow Automation Patient Profile Engagement Medical & QoL Assessment ID of Priorities & Integration With Medical Choices Readiness To Act Assessment Follow Up Call Log Patient Action Plan ACP Docs Deliverables Process Modules (conducted over multiple sessions, typically three-five) Tools Communi- cation & Revision Decision making (Current & Future) Behavioral Stage Action Strategies Plans & Follow-Up Educational Materials for Patient Identification

7. Vital Decisions Living Well Program Process Overview Engagement Medical & QoL Assessment ID of Priorities & Integration With Medical Choices Readiness To Act Assessment Follow Up Process Modules (conducted over multiple sessions, typically three-five) Communi- cation & Revision Decision making (Current & Future) Behavioral Stage Action Strategies Plans & Follow-Up Identification Motivational Interviewing Based Techniques Page 14

8. Study Results